indigenous hospital experiences: a new zealand case study

PATIENT PERSPECTIVES

Indigenous hospital experiences: a New Zealand case study

Denise Wilson and Pipi Barton

Aims and objectives. To explore M�aori (Indigenous people of New Zealand) experiences of hospitalisation in surgical or

medical settings and how these might influence length of stay.

Background. Globally Indigenous peoples with histories of colonisation suffer health disparities compared with other groups.

They experience higher levels of morbidity, premature mortality, lower life expectancies and differential access, use and quality

of health services. In Indigenous communities’ negative anecdotal accounts of hospital experiences indicate more research is

needed about their hospital experiences.

Design. A M�aori (Indigenous) centered approach using case study methodology and three data sources: medical-surgical dis-

charge data, interviews with M�aori and a literature review.

Method. Using statistical data from the New Zealand Health Information Service from 1989–2006, a retrospective interrupted

time series design was used to examine length of stay for M�aori patients in medical and surgical hospital settings. Semi-

structured interviews with 11 participants identifying as M�aori who had experienced hospitalisation in a medical or surgical

setting were transcribed and thematically analysed. A structured review of the research literature on Indigenous hospital

experiences was also analysed. These data were analysed individually, triangulated and interpreted.

Results. M�aori consistently have a shorter average length of stay than non-M�aori using public hospitals in New Zealand.

Marginalisation of Indigenous peoples in public hospitals was evident in both the interviews undertaken and the literature

reviewed. Participants believed hospitals were not conducive to healing and negative experiences contributed to decisions to

seek an early discharge.

Conclusions. Given the disparities in Indigenous health status, health professionals can address negative hospitalisation expe-

riences by attending to the quality of care delivered and nature of the hospital environment.

Relevance to cinical practice. Nurses can play an important role improving health outcome disparities for Indigenous peoples

linked to health service delivery, especially the delivery of culturally responsive and quality nursing care.

Key words: clinical effectiveness, cultural issues, hospital care, Indigenous, nursing, quality of care

Accepted for publication: 14 November 2011

Introduction

Indigenous peoples in New Zealand, Australia, Canada and

the USA with histories of colonisation suffer disparities in

health status and accessing quality of health services,

regardless of their rights to health (United Nations 2007).

Nurses have an obligation to provide equitable and socially

responsible care and to contribute to reducing inequalities

healthcare. Indigenous health is a ‘concern for nurses’

(International Council of Nurses 1998). Given the contact

Authors: Denise Wilson, RN, MA, PhD, Associate Professor, M�aori

Health, School of Public Health & Psychosocial Studies, AUT

University, Auckland; Pipi Barton, RN, MN, Research Officer,

Henry Rongomau Bennett Centre, Waikato District Health Board,

Hamilton, New Zealand

Correspondence: Denise Wilson, Associate Professor M�aori Health,

School of Public Health & Psychosocial Studies, AUT University,

Private Bag 92-006, Auckland 1142, New Zealand. Telephone:

+64 9 921 9999

E-mail: [email protected]

� 2012 Blackwell Publishing Ltd

2316 Journal of Clinical Nursing, 21, 2316–2326, doi: 10.1111/j.1365-2702.2011.04042.x

nurses have with Indigenous peoples they are positioned well

to improve their health experiences and optimise health

outcomes. M�aori (Indigenous people of New Zealand)

experience inequalities in wide-ranging morbidities and life

expectancy than others (Robson & Harris 2007, Ministry of

Health 2010). Despite their health needs, M�aori tend to

receive substandard quality of care and are discharged from

hospitals earlier than others (Davis et al. 2006, Wilson &

Neville 2008). M�aori reluctance to be hospitalised has been

historically, related to limited visiting hours, suspicion and

biomedical approaches (Buck 1949).

The prevalence of poor health outcomes is unacceptably

high among M�aori (Curtis et al. 2007, Reid & Robson 2007)

and connected to access to health services. Despite significant

gains in M�aori health status across the 1950s and 1970s,

major health reforms during the 1990s increased inequalities

between Maori and non-Maori, although narrowing since

(Ajwani et al. 2003, Blakely et al. 2008). Most M�aori expe-

rience significantly higher deprivation, influencing their access

to determinants of health (Blakely et al. 2004, 2008). In

addition, the neo-liberal policies driving health service delivery

during the reforms removed many free health services and

introduced costs (Gauld 2009). Maori health status is com-

plex, influenced by multiple factors like genetics, education,

lifestyle, socioeconomic determinants, access to health deter-

minants and use of health services (Blakely et al. 2008).

M�aori link culturally appropriate care with quality of care

(Reid & Robson 2007). Yet they experience higher rates of

adverse events in hospitals and are likely to receive inappro-

priate care and follow-up (Davis et al. 2006, Jansen & Smith

2006). Nurses are linked to the quality of care delivered in

acute hospital settings (McCloskey & Diers 2005), although

hospitals have limited Indigenous health professionals mean-

ing non-Indigenous nurses are likely to encounter and care for

Indigenous patients. M�aori comprise only 5Æ7% of all health

professions despite being 15% of the New Zealand popula-

tion (Ratima et al. 2007) and 6–7% of registered nurses

(Nursing Council of New Zealand 2010). Undoubtedly, the

co-morbidities many M�aori have makes nursing care com-

plex. Given this and the analysis of hospital administrative

data (not yet published), we aimed to understand M�aori

beliefs and experiences related to hospitalisation, to gain

insight into their shorter length of stay in hospital.

M�aori experiences of hospital care are less than optimal.

Despite M�aori having twice the cardiac disease rate, they

received significantly lower rates of potentially life-saving

interventions, such as angioplasty (Westbrooke et al. 2001).

Westbrooke et al. (2001) highlighted inequitable access to

interventions and quality of care and concluded M�aori

health needs were not being met. Davis et al.’s (2006)

examination of the quality of hospital care received by

M�aori found they were younger and likely to have high

socioeconomic deprivation. Notably, M�aori had statistically

significantly more adverse events (14% of admissions)

compared with non-M�aori (11%) (Davis et al. 2006). M�aori

are also hospitalised with higher rates of avoidable and

amenable hospitalisation rates than others (Ministry of

Health 2010). M�aori women accessing health services also

reported poor quality of care and negative interactions with

health care professionals, culminating in their needs not being

met (Wilson 2004). Further, Bolitho and Huntington (2006)

found M�aori families’ accessing hospital care for a child with

respiratory conditions encountered difficulties attributed to

socioeconomic status and health system barriers. McKinney

(2006) also reported negative hospital experiences for M�aori,

even though nurses are regulated to provide culturally safe

care (Nursing Council of New Zealand 2009).

Differential quality in care can be linked to institutional

racism. Reid et al. (2000) claimed, ‘… negative stereotypes,

victim blaming and deficit explanations continue to be

articulated by nurses and doctors, particularly when Indig-

enous people do not respond positively to prescribed health

interventions’. The delivery of culturally inappropriate ser-

vices, does little to recognise the life circumstances of M�aori,

offering instead health services informed by a biomedical

worldview (Durie 2001, McCreanor & Nairn 2002).

Methods

We used an intrinsic single case study (embedded) design to

determine M�aori experiences during hospitalisation (Stake

1995, Yin 2003) (Fig. 1). It focused on understanding M�aori

medical and surgical hospitalisation experiences and enabled

the identification of actions and interactions in the complex-

ity of hospitals (Hancock & Algozzine 2006). The case was

defined as M�aori hospital experiences.

Consideration of Indigenous eco-spiritual and holistic

worldviews in planning the case study was necessary so

M�aori traditions and processes were observed. Consequently

a M�aori centered approach informed the research process

(Cunningham 1998), underpinned by assumptions that

research must be (a) beneficial to M�aori, (b) respectful of

M�aori in the research and (c) ensure credible research

outcomes (Wilson 2004). According to participants’ wishes,

M�aori protocol and processes informed the explication of the

research process. For example, interviews began with a

karakia (prayer) followed by a process for establishing

mutual connections. All participants received a small gift in

appreciation of their time and willingness to share. These are

important aspects of M�aori cultural practice.

Patient perspectives Indigenous hospital experiences


Journal of Clinical Nursing, 21, 2316–2326 2317

Ethics

Ethical approval was obtained by the university ethics

committee (MUHEC:N 08/031) and for accessing de-identi-

fied medical-surgical hospital discharge data (MUHEC:N 06/

082). Potential participants received an information sheet and

after answering any questions they consented to participate.

Participants’ anonymity was guaranteed by assigning pseud-

onyms and removal of all identifying features from transcripts.

Participants

Participants identifying as M�aori with acute medical-surgical

hospitalisation experiences within the last 15 years qualified

for inclusion in the qualitative phase of the study. Sample size

was determined by saturation of the themes and sub-themes.

Eleven participants fulfilled the criteria for interviews; 10

having hospital experiences within 5 years and one 12 years

prior. Their ages ranged between 20–75 years (median

46 years), nine were female and they affiliated with diverse

Iwi (tribes). Six participants lived rurally, two lived in semi-

urban areas and three were from urban areas.

Data collection and analysis

Multiple sources of evidence were gathered to strengthen the

findings (Yin 2003) and included length of stay data, partic-

ipant interviews and Indigenous research about health service

experiences. Data triangulation brought together findings from

the various sources for scrutiny, consideration of alternative

interpretations and to draw conclusions (Stake 1995).

Length of stay data

New Zealand Health Information Service (NZHIS) collects

administrative data and uses ICD-10 and Australian Refined

DRGs (AR-DRGs) to code inpatient data. Average length of

stay (ALOS) data used was part of a larger study (not yet

published) that explored nursing and M�aori patient outcomes

during three phases of New Zealand health reforms (Phase 1:

1989–1993; Phase 2: 1993–2000 and Phase 3: 2000–2006).

Outcomes Potentially Sensitive to Nursing were used to

measure quality of outcomes – similar to Carryer et al.

(2011) and McCloskey and Diers’ (2005) study which found

nursing resources can impact patient outcomes. We used the

National Minimum Data Set for whole population public-

funded inpatient hospital admissions (>12 million) in 20

District Health Boards offering medical and surgical services

to calculate ALOS for M�aori and non-M�aori hospital

admissions from 1989–2006. M�aori included any admission

recording M�aori ethnicity; all other records were considered

non-M�aori. Algorithms filtered medical and surgical admis-

sions to include only those over 17 years and <90 years,

with a length of stay >1 day and <90 days. We excluded

records with ICD-10 codes indicating major diagnostic cat-

egories (MDC) in obstetrics, paediatrics and mental health.

Data were analysed using Statistical Package for Social

Sciences (SPSSSPSS) Version 17.0. For this study, an annual ALOS

was calculated for each year from 1989–2006 and plotted in

time series to show trend, variability and level for M�aori and

non-M�aori medical and surgical admissions (Fig. 2). The

differences between Phase 1 (1989–1993) and Phase 3 (2000–

2006) of the health reforms were calculated using mean

ALOS for each period.

Semi-structured interviews

Semi-structured, digitally recorded interviews with 11 par-

ticipants were carried out using a mixture of open and closed

questions to ensure key issues were covered. Interviews were

flexible enabling exploration of issues arising. Transcribed

interviews were analysed, which comprised examining,

categorising, tabulating and constantly recombining data

according to the aims of the study (Stake 1995). Each

transcript was initially examined and re-examined to identify

recurring sub-themes. These sub-themes were then analysed

across the interviews to discover recurring themes, which

were categorised by relevance to the research aims. These

were re-categorised and tabulated into themes and sub-

themes.

CONTEXT: Medical or surgical hospital experience

CASE: Māori hospitalisa on experience

Averagelength of

stay (ALOS)data

Structuredreview of the

literature

Interpreta onTriangula on

of findings

Interviewswith Māori

Figure 1 M�aori experiences of hospitalisation as an intrinsic single

case study (embedded) design.

D Wilson and P Barton


2318 Journal of Clinical Nursing, 21, 2316–2326

Structured review of the literature

A structured literature review was undertaken, recommended

when limited research and time constraints exist on a topic

and a wider review than a systematic review is needed (Evans

& Kowanka 2000). CINAHL, ERIC, Medline, Web of Sci-

ence and Google Scholar were searched for relevant literature

relating to M�aori, Indigenous and Aboriginal people using a

combination of keywords: M�aori, Indigenous, Aboriginal,

native, health, illness, hospital, hospitalisation, length of

stay, ethnicity, inequalities, disparity and nursing. Literature

was included for review that related to Indigenous experi-

ences of hospitalisation. The structured review involved

comparing and analysing publications for similar themes

arising.

Results

Interview participants generally had acute medical or

surgical experiences in larger urban public hospitals. Their

length of hospital stay ranged from 2–84 days. Two of the

11 participants were readmitted following discharge and

three experienced adverse outcomes while an inpatient (for

example, hospital acquired infection). Two over-arching

themes, ‘A foreign environment’ and ‘Wh�anau (extended

family) Caring for Wh�anau’ and seven sub-themes emerged

from the analysis (Table 1). The results relating to length of

stay and findings of the interviews are presented separately,

with the structured literature review findings integrated.

The interpretation of the findings is presented in the

discussion.

Average length of stay

The ALOS confirmed M�aori were likely to be discharged

from hospital earlier than others (Fig. 2). A downward trend

in ALOS for both M�aori and non-M�aori from 1989–2006

was evident, reducing overall from 7Æ0–5Æ3 days (a 24Æ3%

reduction). Figure 2 demonstrates M�aori consistently had a

shorter ALOS in both medical and surgical settings, even

though non-M�aori experienced a greater percentage reduc-

tion in ALOS (33Æ7% for medical; 26Æ2% for surgical) than

M�aori (28Æ4% for medical; 16Æ7% for surgical). The ALOS

inequality remained for M�aori: 1Æ6 days in medical settings

and just under half a day in the surgical settings (Table 2).

Interview and literature findings

Theme 1: A foreign environment

A foreign environment portrays hospitals as unfamiliar

environments for M�aori, dominated by Western biomedical

worldviews, models of care and interventions. Hospital

200620052004200320022001200019991998199719961995199419931992199119901989

9·0

8·5

8·0

7·5

7·0

6·5

6·0

5·5

5·0

4·5

4·0

Non-Māori surgicalMāori surgical Non-Māori medicalMāori medical

Ave

rage

leng

th o

f sta

y in

day

s

Year

Figure 2 Annual average length of stay in days for M�aori and non-

M�aori medical and surgical patients 1989–2006.

Table 1 A summary of the themes and sub-themes arising from the

interviews

Theme Sub-themes

A foreign environment

Hospitals are unfamiliar

environments causing great

discomfort

Hospital environment

• Dominated by a biomedical,

worldview, models of care and

interventions

Understanding the system

• Hospital systems and processes

are complex and overwhelming

Discharge bargaining

• Discomfort and negative

experience lead to patients

leaving early

Family caring for family

The involvement of family

members in the care of their

relative to ensure quality of

care and meeting cultural and

spiritual needs

Caring for a family member

• Family members care for their

relative and other indigenous

patients who are without family

Reason to mistrust

• Actions and lack of actions by

nurses and other health

professionals lead to feelings of

mistrust

Quality of care

• Care by nurses is either

substandard or absent, and noted

to be different to that given to

other patients

Don’t complain

• Fear of reprisal results

indigenous patients and their

family reluctant to complain




experiences were overwhelming, caused great discomfort and

could contribute to M�aori seeking an early discharge. A

foreign environment comprises three sub-themes: ‘the hospi-

tal environment’, ‘understanding the system’ and ‘discharge

bargaining’.

The hospital environment. The hospital environment and its

biomedical culture contributed to M�aori having a shorter

length of stay and a belief their health needs were not met.

Hospitals were the antithesis of a healing environment,

instead created discomfort, anxiety and stress for M�aori,

engendered a sense of alienation and exacerbated the urge to

be discharged; M�aori believed hospitals better catered for

patients from the dominant culture, especially as their

cultural beliefs and practices were generally not considered.

As a result their spiritual and cultural needs were compro-

mised in exchange for needed health care. The nature of the

environment contributed appreciably to M�aori experiencing

anxiety and fear of death while in hospital. Consequently,

they struggled to feel comfortable while in hospital:

Hospitals are a place of sickness and death. So you don’t want to be

around that if you want to be well. There is an energy about

hospitals, there is a sickness to it and you don’t want to be in the

middle of that. … (03:5:14)

Understanding the system. Understanding complex hospital

systems and processes was problematic, making it difficult for

M�aori to navigate the hospital and understand its day-to-day

operations. Simply, it was a source of confusion. Participants

felt disadvantaged, especially when nurses and doctors

inadequately explained procedures and treatments. Family

members were often required to interpret information for the

patient, generally with little information themselves:

Mum was really agitated and she was, ‘What are they doing?’ I said,

‘Mum, they are putting a thing in you to drain water’. That was all I

could say, that’s all I understood it to be, I didn’t really know why.

(09:1:5)

Having to pursue nurses for information about their treat-

ment and care made them feel they were a nuisance and an

inconvenience.

Discharge bargaining. As mentioned earlier, M�aori ALOS

was less than others admitted to medical and surgical

settings. While some participants reported being discharged

‘early’ (before they were ready), others reported engaging in

discharge bargaining. Feelings of alienation and discomfort

motivated early discharge bargaining, where participants

bargained with doctors and nurses to leave hospital early.

Furthermore, they often stretched the truth ‘a little’ to

convince staff they could go home:

I was supposed to have someone with me 24 hours according to the

doctors and staff. . . I knew they [the family] wouldn’t be able to do

it, but I kind of told the doctors, ‘oh yeah, yeah’ because the other

option was staying in hospital and I wasn’t keen on that. (03:3:9)

Early discharge placed relatives, who often became primary

caregivers, in unenviable positions of persuading their rela-

tive to stay in hospital to receive needed treatment despite

their relative’s distress when remaining in hospital:

She would have let herself out much earlier, we begged her to stay

until we found out [what was wrong]. (02:1:16)

The hospital was also a foreign environment for other

Indigenous peoples, where feelings of alienation, discomfort

and mistrust were intensified by universal approaches to care

delivery (Reid et al. 2000, Jansen & Smith 2006). For

Australian Aboriginal people, hospitals made them feel

unsafe and caused fear, distress and hardship. Spiritually

they wanted to die at home where they were connected to

land and family, often in rural and remote areas (McGrath

2007). Canadian First Nations women felt like intruders, also

alienated and unable to connect with health professionals.

Their encounters were shaped by ‘… racism, discrimination

and structural inequalities that marginalised and disadvan-

taged Indigenous people’ (Browne & Fiske 2001, p. 126).

Table 2 The difference in the average length of stay between M�aori and non-M�aori 1989–2006

Medical ALOS (days)Difference between

M�aori & non-M�aori

(days)

Surgical ALOS (days)Difference between

M�aori & non-M�aori

(days)

Overall

Average

(days)M�aori Non-M�aori M�aori Non-M�aori

1989–1993 6Æ0 8Æ0 �2Æ0 6Æ6 8Æ0 �1Æ4 7Æ02000–2006 4Æ3 5Æ9 �1Æ0 5Æ5 5Æ9 �0Æ4 5Æ3Difference (days) �1Æ7 �2Æ7 �1Æ1 �2Æ1 �1Æ7% Difference �28Æ4% �33Æ7% �16Æ7% �26Æ2% �24Æ3%




Participants found understanding hospital systems and

processes advantageous; nevertheless familiarity with the

dominant culture did not guarantee they could navigate them

without frustration or difficulty. The complexity and a

seemingly patronising and paternalistic culture among hos-

pital staff further disadvantaged Indigenous people (Cram

et al. 2003). The Mi’kmaq First Nations community of

Canada reported feeling like strangers within the hospital

system and also experienced frustrations and difficulties

understanding the ‘hospital world’, its rules and treatments

(Baker & Daigle 2000). They believed their queries inconve-

nienced nurses and doctors and left them to feel misunder-

stood and maligned.

Theme 2: Wh�anau (extended family) caring for Wh�anau

Despite the apparent availability of nurses to provide care,

family members undertook care of their relative during hos-

pitalisation. The care provided by family enabled patients’

cultural and spiritual needs to be met. Those without family

went to great lengths to manage their own care as soon as they

were able. The sub-themes are ‘caring for a family member’,

‘reason to mistrust’, ‘quality of care and don’t complain’.

Caring for a family member. Necessity led to family

members carrying out personal cares without question.

Necessity for wh�anau to care for M�aori patients emerged

from observing differences in care than other patients, with

their care being either substandard or ignored. In such

cases, M�aori patients preferred family members over nurses

to care for them because they knew they would receive

adequate care. Furthermore, family members invariably

understood the patient, were able to attend to their

physical and cultural needs and were a source of comfort.

Although in some instances family members felt forced to

tend to their relatives’ basic personal needs as nursing staff

appeared too busy or gave the impression they were a

nuisance:

We’d ring the bell … they’d come in and they’re just grumpy that

you’ve rung them. I don’t know if it’s because we’re M�aori or we are

being a nuisance. I didn’t feel like I was being a nuisance. (05:9:9)

Family members found themselves also ‘looking out’ for

other M�aori patients who needed support and advocacy as

their family were not present. This sometimes involved

speaking to nurses on the patients’ behalf or providing

meaningful information:

I’ve spoken up for kids who aren’t even my kids, brown kids, because

they need to know there’s an ‘aunty’ sitting across in the other bed

that will stand up for them. (04:1:12)

Reasons to mistrust. Frequently poor communication and

lack of information about care and treatment were encoun-

tered. Lack of information was distressing and compounded a

sense of mistrust. Participants questioned whether they were

treated differently because they were M�aori, particularly

when they observed staff interacting differently with other

patients. Participants believed staff actions and negative

judgments were based on race:

By the time we got in there … the doctor, he gave me a hard time

about it, like I was a neglectful mother. And that’s the other thing …

they interrogate you because you’re brown. (05:1:4)

Everything is done in a kind of Western way … I just distrust them,

it’s just rituals and stuff – it’s their belief system. (03:3:13)

Quality of care. At times, quality of care was questioned

when differences were observed – care was not as it should be

and staff appeared intolerant of M�aori patients’ needs. Such

behaviours were interpreted to be discriminatory and racist.

However, speaking up about the quality of care involved

M�aori having to justify their concerns and risked being

further subjected to inappropriate and unprofessional behav-

iours from nurses or doctors:

I’m always watching how do they say hello to that parent and how do

they say hello to me. You know, it’s often not the same. (05:15:12)

Don’t complain. Despite substandard care in hospital, M�aori

were reluctant to complain. They felt a sense of powerlessness

and avoided the potential for reprisal by hospital staff.

Feeling unable to address concerns contributed to a lack of

trust in the health system:

I had found out I could make a complaint if I wasn’t happy with some

of the care … I spoke to my older sister … she said just to leave it

because she felt Mum might get alienated next time. (09:1:11)

M�aori experiences are not dissimilar to other Indigenous

peoples. Marginalisation of Native American women was

indicative of the quality of care they received (Dodgson &

Struthers 2005). Mistrust intensified when nurses and doctors

were disrespectful, abrupt, inattentive, lacking authenticity

and did not understand the hardship Indigenous people

experienced. Health care providers were prone to functioning

on negative stereotypes and assumptions when working with

Indigenous women (Dickson 2000, Kurtz et al. 2008). Kurtz

et al. (2008) found colonial structures and systems silenced

Canadian Aboriginal women and subjected them to racism –

the darker their skin colour, the worse the treatment they

received.




Similar to M�aori, the presence of Australian Aboriginal

family members in hospital is grounded in the belief that

constant family support aids recovery (Garvey et al. 2004).

Participants’ experiences of ‘looking out’ for other M�aori

patients is similar to that described by Baker and Daigle

(2000), where Mi’kmaq First Nations people sought out

other Mi’kmaq people for support and comfort, creating a

‘cultural umbrella’ in a foreign hospital environment. Nev-

ertheless, Mi’kmaq peoples’ hospital experiences resulted in

feelings of alienation, isolation and discomfort in the hospital

environment (Baker & Daigle 2000). Similar to M�aori in this

study, Mi’kmaq participants wanted to leave hospital as soon

as they possibly could.

Discussion

Nurses play an integral role in improving the health outcomes

of Indigenous peoples and minority groups (Wilson 2003).

Undeniably, the ongoing presence of global disparities in

Indigenous and minority health outcomes is a human rights

and social justice issue. By triangulating data sources it was

possible to draw interpretations and conclusions about M�aori

and Indigenous hospital experiences and their relevance for

the practice of nurses and other health professionals. The

focus of the following discussion is on three key interpreta-

tions that emerged:

1 Indigenous people are marginalised within mainstream

health systems.

2 Hospital environments tend not to be conducive to healing

for Indigenous people.

3 Negative hospital experiences appear to contribute to

Indigenous people making decisions about early discharge

(Fig. 3).

Indigenous people are marginalised within mainstream

health systems

M�aori have a legitimate right guaranteed under the Treaty of

Waitangi (an agreement signed in 1840 between M�aori and

the Crown) to equal health care. Despite this, M�aori

consistently experience substandard health services when

compared with non-M�aori (Davis et al. 2006, Reid &

Robson 2007). Differences in quality of care are an indicator

of institutional and interpersonal racism in health service

delivery and are associated with differential health outcomes

(Jones 2000, Karlsen & Nazroo 2002, Nazroo 2003). M�aori,

similar to other Indigenous and ethnic minority groups, have

a higher prevalence of exposure to racism and discrimination

that is considered a determinant of health in New Zealand

(Dickson 2000, Karlsen & Nazroo 2002, Harris et al. 2006,

Kurtz et al. 2008).

Participants’ recounts provided a unique insight into M�aori

experiences of hospitalisation, similar to other Indigenous

peoples and minority groups, and highlighted marginalisation

in the health system (Browne & Fiske 2001, Dodgson &

Struthers 2005, Wilson & Neville 2008). Similar experiences

were also encountered by those belonging to minority groups

or culturally and linguistically diverse communities in New

Zealand, Northern America and the UK and Europe (Betan-

court et al. 2003, El Ansari et al. 2009, Hesselink et al. 2009,

Peters et al. 2009, Mortenson 2010, Sorkin et al. 2010).

Despite Indigenous status and rights for M�aori guaranteed

under the Treaty of Waitangi, their continued marginalisa-

tion in the health system is disturbing.

Marginalisation appears to be perpetuated by dominant

biomedical views of health and the apparent inability for

mainstream health service providers to adapt services to

accommodate patients’ alternative views (Dodgson & Stru-

thers 2005, Mitchell & Weerasinghe 2007, Wilson & Neville

2008. Holism and individualised care, as cornerstones of

nursing, become merely rhetorical constructs when spiritual

and social contexts are ignored by health professionals

(Wilson & Neville 2008). To avoid marginalising Indigenous

patients and families, nurses need to have a critical under-

standing of their historical and contemporary socio-political

experiences, undertake a critical reflection on their own beliefs

and values and the impact on their practice and be willing to

accommodate patients’ beliefs and practices in the delivery of

nursing care (Ramsden 2002, Barton & Wilson 2008).

Indigenouspar cipants’

recounts

Indigenous literature

Three keyinterpreta ons

Average length of stay data

1. Indigenous people are marginalised in the New Zealand health systems

2. Hospital environments tend not to beconducive to healing for Indigenous people

3. Nega ve hospital experience appear to contribute toIndigenous people making early discharge decisions

Figure 3 Key interpretations about Indigenous hospital experiences

following triangulation of the data.




Hospital environments tend not to be conducive to healing

for Indigenous people

Health perspectives are constructed within a person’s unique

socio-cultural context. As mentioned earlier, Indigenous

peoples have an eco-spiritual holistic worldview driven by

strong spiritual beliefs and their connection to the land and

other living things. This holistic worldview provides indica-

tors of influences to their well-being and is contrary to the

biomedical worldview in hospitals that tends to be illness or

problem focused (Baker & Daigle 2000, Dodgson & Struthers

2005, Mitchell & Weerasinghe 2007, Wilson & Neville

2008). This contributes to the belief hospital environments

generally are not conducive to spiritual and mental healing –

crucial components of Indigenous health and well-being.

Health does not exist independently, but is part of a myriad of

interconnecting and interdependent dimensions responsive to

various external forces (Durie 2001, Cram et al. 2003, Wilson

2004, El Ansari et al. 2009, Weersinghe & Mitchell 2009).

On the whole, Indigenous peoples, similar to other ethnic

minorities, strong collective orientations are linked to their

sense of well-being and healing. Holistic worldviews need to

be acknowledged in respectful and collaborative ways as

assimilation into mainstream health services can be difficult

for Indigenous people when unwell (Cram et al. 2003).

Integral to Indigenous cultures are traditional healing

practices. For example, traditional healing for M�aori includes

medicines gathered from the environment, traditional mas-

sage and prayer. Of special significance are traditional

healers, such as tohunga for M�aori, although generally

family have a significant role in M�aori health and well-being.

Nevertheless, hospital environments generally do not accom-

modate traditional healing practices and M�aori patients often

wait until they return home to use traditional healing

practices. This averts a potential refusal or reproach by

hospital staff when seeking permission to use traditional

medicines in hospital. Simply, hospital environments are not

necessarily seen as safe to carry out traditional practices.

Indigenous families want to ensure patients receive cultur-

ally appropriate care. Nurses have a role in determining the

needs of Indigenous people for their incorporation into care

plans to facilitate healing in a genuine and non-judgmental

manner and aid spiritual well-being. Yet, we found nurses

often neglected their responsibilities, leaving family to pro-

vide personal cares, such as showering, especially when their

body language discouraged requests for help. Ideally, nurses

should consider building relationships with patients and

family members to identify not only information and care

needs, but also cultural requirements and how these can be

included in care plans.

Negative hospital experiences appear to contribute to

Indigenous people making decisions about early discharge

Quality of care is a determinant of health outcomes (Hasn-

ain-Wynia et al. 2007). Quality nursing care is important in

preventing negative outcomes that are potentially sensitive to

nursing (McCloskey & Diers 2005). Patient health care

needs, safety, effectiveness, patient-centeredness and timeli-

ness are all components of health care quality (Lurie 2002).

While our study is small, it nevertheless provides insight into

the experiences of M�aori and the need to reinforce important

nursing care fundamentals. High rates of inequalities in

morbidity and mortality imply M�aori, similar to other

Indigenous and ethnic minority groups, need comprehensive

quality care (Ajwani et al. 2003, Cormack et al. 2007,

Harwood & Tipene-Leach 2007, Blakely et al. 2008, El

Ansari et al. 2009, Hesselink et al. 2009, Peters et al. 2009),

yet they potentially have less time in hospital and are likely to

receive substandard care.

Our finding that M�aori are more likely to be discharged

earlier than non-M�aori is confirmed by others (Westbrooke

et al. 2001, Ministry of Health 2006, Robson & Harris

2007). This raises the question, ‘If M�aori are leaving hospital

earlier than non-M�aori, is it detrimental to their health or

their recovery?’ Early discharge is counterintuitive given for

M�aori there is a high prevalence of chronic health conditions

and premature death. Improving the quality of interactions

with health professionals and care is crucial to address the

inequalities in health care.

Despite articulation of the importance of culture in health

care and nursing in nursing literature for four decades

(Leininger 1970), marginalised and vulnerable groups con-

tinue to be the recipients of culturally inappropriate and

unacceptable health care (Baker & Daigle 2000, Dodgson &

Struthers 2005, Reid & Robson 2007, Wilson 2008, Wilson

& Neville 2008, El Ansari et al. 2009). Marginalisation of

Indigenous peoples in hospitals is not conducive to healing

and potentially contributes to inadequate hospital care.

Having said this, M�aori, like other Indigenous peoples,

attempt to make the best of the situation by seeking out

information and providing direct care and cultural comfort to

their relatives. Culturally safe and competent practice

requires nurses to examine their own cultural beliefs and

practice and how these may impact on others and to respect

the cultural needs of patients (Ramsden 2002, Wilson 2008).

Nurses can begin by critically analysing their attitudes and

behaviours toward people and their family who belong to

Indigenous and other minority groups and identifying what

personal and professional development is needed to improve

their practice.




Limitations

This study has limitations. While it provides insight into the

hospital experiences of Indigenous people it is a small study,

thus the findings should be used cautiously in other contexts.

Also those interviewed were predominately female, despite

men being invited to participate in the study. Future studies

should explore ways M�aori men can be better recruited into

the study. The inclusion criterion of having a hospital

experience within the previous 15 years is a potential

limitation, although all except one participant was hospita-

lised within five years of their interview. The 15 year time

period related to the time span of the ALOS data, supported

by the anecdotal information indicating for many M�aori

hospital experiences had not improved over this time. There a

strong likelihood the hospital administrative data has under-

counted M�aori, as M�aori ethnicity definitions underwent

several changes between 1986–1996.

Conclusion

Indigenous peoples, similar to others belonging to minority

and culturally and linguistically diverse groups, suffer

appalling disparities in health status and outcomes, which

in part can be connected to the quality of care delivered by

health services. In this study, M�aori experiences of hospital-

isation suggested substandard care and the nature of the

hospital environment reinforced beliefs about hospitals and

health professionals they held. Indeed, recounts of personal

and cultural isolation, poor communication by nurses and

doctors and racist and discriminatory practices are evident in

other studies. Despite nursing endeavours to provide cultur-

ally appropriate care to Indigenous and other minority

groups, hospital environments appear to continue to mar-

ginalise them. For this reason it is understandable that M�aori

would choose to leave such an environment as early as they

can. Nevertheless nurses can create positive health experi-

ences to optimise hospital experiences and health outcomes.

Relevance to clinical practice

Indigenous peoples have health outcome disparities linked to

health service delivery. Nurses have an important role in

providing a culturally appropriate and safe environment and

by being welcoming and non-judgmental. Quality nursing

care involves establishing relationships with patients and

families and incorporating cultural beliefs and practices into

care plans.

Acknowledgements

This research was undertaken as part of a Health Research

Council funded project.

Contributions

Study design: PB DW; data collection and analysis: PB DW

and manuscript preparation: DW PB.

Conflict of interest

None.

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