Sage Journals: Discover world-class research

Abstract

Healthcare in Aotearoa New Zealand is changing with the aim of becoming truly universal. Development of a new curriculum model in the education of health professionals can aid this goal through increased focus on community needs and flexibility for multiple health professional registrations. Universal healthcare and disability support are promoted as a defining feature of Aotearoa New Zealand, yet inequities are blatantly evident, with increasing calls for equity. Complexity of the issue and the multitude of stakeholders favour action research founded on Vision Matāuranga, a problem-solving philosophy which embraces the potential for innovation of Māori – people, knowledge and resources. Action research embraces collaboration with stakeholders to identify and implement solutions. Government ministries determine policy, with Responsible Authorities accrediting educational institutions, which in turn provide educational programs. Changing what and how students learn can increase their understanding of equity and community needs when they become practitioners, with the voice of service users being paramount.

Keywords

Vision matāuranga action research health professional education health practitioners’ competence assurance health professional regulation lived experience

Introduction

E koekoe te tūi, e ketekete te kākā, e kūkū te kererū

The tui chatters, the kākā cackles, the kererū coos

This whakatauki (proverbial expression incorporating wisdom and values) can be interpreted as ‘By appreciating all our voices, our different songs, we make good music for the future’. The tūī, kākā and kererū are all native birds, however each is distinctively different and significant (Edwards, 2009). This philosophy underpins an Auckland University of Technology Health Futures research project which arose from a recent review of the health and disability system. It is currently being undertaken at the university to address key issues in order to identify and implement change in the future education of health professionals. The project, funded for three years by the Health Futures initiative and based in the Faculty of Health and Environmental Science, aims to help address the issues of inequitable health outcomes and lack of flexibility in health professional education. The project contributes to development of a new curriculum model by recognising the diverse voices of key stakeholders

The need to re-envisage the way we educate health professionals in Aotearoa New Zealand arises from current inequities in access, experience and outcomes amongst users of the healthcare system. Healthcare, as for other elements of the welfare state, involve many moving parts including public funding, infrastructure, service provision, quality management and health professional practice. Concern is growing about the perceived ‘disconnect’ between the users of health services and the system that provides such services, particularly for Māori (e.g. Brown and Bryder, 2022). In response to this concern, the Health and Disability System Review, 2020 (known as ‘The Simpson Report’) was undertaken and highlighted the need for system transformation including improved workforce planning and curriculum development based on better engagement between education providers, service providers and communities. The report specifically states that ‘It is important that the future (health) workforce represents the communities it serves, is safe and competent, works in a culturally safe way, and can work well as a team to provide high-quality person and whānau-focused (family focused) care’ (p.193).

As educationalists, we are using an action research process to support change in health professional education, that can assist in addressing inequities in healthcare, in particular for Māori. An educational goal is to redesign the content and process of curricula to bring about positive change in what is taught and how it is taught, while also providing flexible routes to qualification and registration, reflecting the many voices of Aotearoa New Zealand.

We are a multi-disciplinary project team working collaboratively as co-investigators to interweave research and action. The team includes health professionals, Kaupapa Māori researchers, experienced and emerging researchers with social science, health and business backgrounds, teaching academics and service users. Stakeholders will be invited to share in the design of the research through offering feedback which in turn informs and monitors progress, enabling change to occur.

Our paper contributes to educational discourse about curriculum changes for graduate health professionals. Based on Dean et al.’s (2020) description of an academic position paper, we examine this current healthcare issue and its background, in relation to scholarly literature, and respond with recommendations or a potential solution to this problem or issue. The paper is presented in sections each of which problematise and offer solutions to address the issue of service delivery, workforce development and educational design and provision. After setting the scene and presenting key frameworks, we examine the perspective of all stakeholders. The discussion and conclusions outline how re-envisaging the education of health professionals contributes to improved healthcare service provision in Aotearoa New Zealand.

Setting the scene

Universal healthcare and disability support is promoted as a defining feature of Aotearoa New Zealand. The comprehensive healthcare and disability support system has a long history of professional regulation and educational development. Universal access is a key tenet of the philosophical approach that underpinned the establishment of the system (Goodyear-Smith and Ashton, 2019). A sense of pride is attached to universal systems of healthcare which then contribute to a sense of national identity (Garrod, 2019; Hiam et al., 2019). Aotearoa New Zealand is noted for its universal model of healthcare and for being one of the first nations to establish such a system, but inequities have become obvious (Goodyear-Smith and Ashton, 2019). Increasing evidence and the voice of health service users illustrate inequitable access and health outcomes, especially for Māori. This has been recognised in part by the New Zealand government announcing the establishment of a Māori Health Authority (Broadbent, 2022; Taylor, 2022).

The education of health professionals is a key element in the healthcare and disability support sector. Changing what and how health students learn has the potential to ensure they genuinely understand and address inequities when they graduate and become practitioners. Qualifications are founded on competencies required by healthcare Regulatory Authorities. Inequities in competencies with respect to Te Tiriti o Waitangi were identified by Came et al. (2021). Te Tiriti o Waitangi is both a founding and a living document, signed in 1840 between the British Crown and Māori as the indigenous people of the land (Tangata Whenua). Came et al. recognised considerable variation in the reviewed competency documents and suggested ‘alternative competencies that could strengthen Te Tiriti engagement’ (p.35). These additional competencies can contribute significantly to improving healthcare practice and are worthy of consideration in any graduate qualification.

Creating more expeditious routes through qualifications also has the potential to enhance workforce diversity and flexibility. Currently the flexibility of the workforce is significantly reduced by the design of qualifications, in particular the time-frame required for a health professional to train (or re-train) for a related field. For example, a nurse wishing to train as a paramedic currently undertakes most of the training for the second qualification, despite considerable common knowledge and skills shared between the two disciplines. A less complex career path can also enable a health professional to practice in two fields concurrently thus potentially creating greater flexibility, especially in smaller and rural communities. It can also retain health professionals within the health workforce rather than move to an entirely different sector, if seeking a change in their work.

The Faculty of Health and Environmental Science is ideally placed to undertake this study. It provides a wider range of health professional education than any other institution in New Zealand in terms of the number of students and the range of professions offered. This experience gives a broad perspective from which to reflect on and reconsider how we educate health professionals and to enact change. Eleven of our programs prepare students for registration under. The project’s specific aims are to help to address inequitable health outcomes and complex pathways that reduce flexibility of the workforce.

The complexity of the problem cannot be over-stated. A curriculum structure will be re-envisaged as part of this project. The content and the learning journey of students will be considered, with the intention to bring about change that enables improved access to care and support, thereby creating optimal health outcomes and experiences for users of health services.

Frameworks

The complexity of this issue and the multitude of important stakeholders make action research founded on Vision Matāuranga an ideal process for enabling action.

Complexity of the problem

This issue can be described as a complex problem without a ‘definitive solution … because different stakeholders bring different perspectives to the problem’ (Waddock et al., 2015: p.1000). Using the complex problem typology of Alford and Head (2017), change in health education is ‘a politically turbulent problem’ (p. 402), – the problem is clear, but the solution is not, ‘with information fragmented and a power imbalance amongst stakeholders who have conflicting interests’.

The two dimensions in this typology are: (a) the nature of the problem and solution and (b) the people involved in problem-solving. Mid-range complexity on the first dimension arises when the nature and cause of the problem is known but it is difficult to find a sound and universally accepted solution. The second dimension significantly impacts on the ability of key people to address the problem. Three factors influence the second dimension: (a) relevant knowledge is fragmented amongst stakeholders, (b) stakeholders have conflicting interests and (c) an imbalance of power amongst stakeholders. With regard to the education of healthcare professionals, all of these factors place the issue at the most complex end of the second dimension and demonstrate why the involvement of a full range of stakeholders in developing a solution is so important.

Vision Mātauranga

Vision Mātauranga aims ‘to envision knowledge, to think about new ways of doing things, to find answers, to solve problems’ through ‘the innovation potential of Māori knowledge, resources and people to assist New Zealanders to create a better future’ (Ministry of Research Science and Technology, 2007: p.2). It was developed as policy by the Ministry of Research, Science and Technology and was incorporated as a pivotal strategy and policy for Crown research institutes in 2011. One of four key research themes of Vision Mātauranga is Hauora/Oranga: Improving Health and Social Wellbeing. This theme draws on the Health Research Council Strategy to improve Māori health and wellbeing, including whenua (land). It aims to support research activities to ‘improve tangata whenua access to quality health services’ and to ‘improve health service provisions to tangata whenua’. For the Hauora/Oranga theme (improving health and social wellbeing), the Vision Mātauranga framework embraces both Māori and non-Māori researchers contributing to the delivery of the desired outcomes (Ministry of Research Science and Technology, 2007: p.13).

Action research

An action research approach founded on stakeholder involvement and partnership is the methodology being used for this project. Bradbury et al., 2019a, p.1) describe educational action research as ‘transformative social learning with a change agenda. It shapes the world with others in a more desired direction’. Therefore, a key principle is that stakeholders in a system are actively involved in ‘transforming structural forces that inhibit thriving’ (Bradbury et al., 2019b: p.3.).

With an aim of working towards the ‘flourishing’ of people and their communities, action research is a natural fit with Vision Mātauranga. It brings together ‘action and reflection, theory and practice, in participation with others, in the pursuit of practical solutions to issues of pressing concern to people’ (Bradbury, 2015, p. ix). Broad characteristics of action research are a collaborative and democratic partnership, an approach to problem-solving and a focus on research in action (Coghlan, 2019). Bradbury et al., 2019a highlight the importance of ‘shared learning amongst people with a stake in transforming structural forces that inhibit thriving’ (p.9). One of the examples discussed by Bradbury et al., 2019a is a change in a healthcare setting that needed transformation. The approach is immensely valuable for problems that are seemingly too difficult to solve. It is a dynamic process that connects change agents and the community and also action and reflection. The action-oriented nature of the methodology results in iterative cycles of collective planning, taking action, evaluating the action, leading into further planning and action.

Stakeholders

Critical to the action research philosophy is the collaborative involvement of all members of a system. In the case of health education, overall competencies for registration of health professionals are determined by Responsible Authorities (RAs) in Aotearoa New Zealand. Regulatory Authorities are healthcare occupational organisations that register practitioners for professional practice, bound by the Health Practitioners Competence Assurance Act (2003). These RAs also accredit educational institutions, which in turn design and deliver educational programs. The graduates from these programs belong health professionals providing healthcare to the community. Each of these stakeholder groups are now discussed.

Māori community and wellbeing

Te Tiriti o Waitangi included assurances that Māori would have the same rights as British subjects along with protection of their chieftainship and treasures. Despite these undertakings, Māori have significantly poorer health outcomes and experiences in seeking care and support (Goodyear-Smith and Ashton, 2019; Palmer et al., 2019). Māori adults report high rates of most health conditions and until recently relied on these being addressed through the current healthcare provisions in Aotearoa New Zealand (Goodyear-Smith and Ashton, 2019). The new Māori Health Authority which ‘will work with Iwi-Māori Partnership Boards, Māori health providers, iwi, hapu and Māori communities to understand Māori health needs across New Zealand’ (New Zealand Government, 2022). The Health Futures project will be informed by directions arising from this fundamental change to the health service.

Decades ago, nursing educators in Aotearoa New Zealand embarked on a journey which resulted in the wide acceptance of ‘cultural safety’ into curricula (Ramsden, 1993). Cultural safety is clearly distinguishable from more generic concepts such as cultural competence (Curtis et al., 2019) and is very specific to Aotearoa. Deliberate attempts to reference Māori concepts, experiences and values into health professional education and practice have evolved in a range of disciplines including medicine (Al-Busaidi et al., 2018; Pitama et al., 2018), health promotion (Ahuriri-Driscoll et al., 2021) and others. Cultural safety is considered highly significant across professions; it is embedded in education and clearly articulated in requirements for professional registration, scopes of practice, professional competencies and expectations of employees (McKenna, 2020).

Public agencies, including the Ministry of Health, publish aspirations and plans to address inequity such as Whakamaua, the Māori Health Action Plan 2020–2025 (Ministry of Health, 2020). This plan emphasises the need for a comprehensive approach that sets goals, measures outcomes, and actively addresses issues with access, service delivery, resources and workforce. While policy and leadership are important, every element of the healthcare and disability support experience, including the physical environment (Ku Leuven, 2019), also matters to Māori.

Despite these obvious steps to ensure the Māori worldview (Mātauranga) is acknowledged, and entitlement to services and equitable outcomes are addressed, there remains considerable inequality in wellbeing and life expectancy. Such systemic inequalities result from colonialism (Hobbs et al., 2019; Reid et al., 2019) and represent a failure to honour Te Tiriti o Waitangi (Came et al., 2021) in ways that are truly meaningful. The problem is less one of inaction but rather of a lack of understanding of Māori, their contexts and wellbeing, and as Wepa and Wilson (2019., p.4) have argued, ‘the worldview of the New Zealand health system is predominately a Western biomedical approach that for the most part focuses on individuals and their health experiences’.

Addressing inequity in access to health and support and the resulting experiences and outcomes, requires fundamental changes to the prevailing narrow understandings of how health is defined, and to broaden this to embrace connectedness to whenua (land) and whānau (family), spirituality and the centrality of these in wellness and wellbeing. However, the existence of policies and structures in themselves does not necessarily result in positive change (Ferdinand et al., 2020) and are insufficient in isolation from the wider context.

Lived experience of the users of health services

The voice of the health service users is formally acknowledged in the work and oversight of government agencies including the Health and Disability Commissioner, the Health Quality and Safety Commission. It is also evident in the certification of health services by the Ministry of Health. Other interest groups and agencies such as Te Pou (a national workforce centre for mental health, addiction and disability in New Zealand), CCS Disability Action, the Mental Health Foundation and Patient Voice Aotearoa also actively present the experiences of patients, caregivers and whanau in relation to service access and provision. Patient voice initiatives can serve a valuable purpose in undergraduate education (Dijk et al., 2020) and the inclusion of the service user voice in governance is an essential requirement for true stakeholder engagement (Akmal and Gauld, 2020).

Despite this recognition, people continue to experience services in ways that require attention, and their feedback about service provision does not lead to sufficient change. Several initiatives have publicly articulated the voices of service users and their call for change. The People’s Mental Health Report (Elliot and Cloet, 2017) presented the perspectives of those with expertise as service users. Recommendations included an inquiry into the structure and provision of services, urgent increases to funding, and independent oversight of the system. A recent report into the experience of people living with harm caused by surgical mesh was prepared for the Ministry of Health (Wailling et al., 2019). This report illustrates how service user voices can be valued and used to inform government agencies.

Increasing representation of people with first-hand experience of health challenges is not new, in particular, people with lived experience of mental health and addiction services have been actively involved in academic settings for some time (Classen et al., 2021; Happell et al., 2014). Classen et al. (2021) further argue that increasing representation of people with first-hand experience of mental health and addiction improves student’s preparedness for practice, empowers mental health consumers and has the potential to reduce stigma and improve outcomes for such marginalized groups. In summary, including the service user voice in the curriculum and learning journey of health professional students has the potential to establish relevant and meaningful understanding of issues and therefore the ability to transform their practice.

Education and health sector: current curricula

The education of health professionals and regulation of their practice is highly controlled in Aotearoa New Zealand. Individual regulators are in place for a number of professions and established as RAs under the Health Practitioners Competence Assurance Act (2003). Analyses of the requirements for educational programs and the competencies of practitioners (Shaw and Donaldson, 2020) indicate that knowledge of Te Tiriti and cultural safety in the context of Aotearoa New Zealand are expected. While these concepts are present, they tend to lack depth with an emphasis on knowledge and personal reflection (Heke et al., 2018).

A starting point is the critical analysis undertaken by Came et al. (2021) of competencies of healthcare professionals set out by the Regulatory Authorities which issue annual practising certificates to ensure practitioners work within their professional scope of practice. This critical analysis aligns to the four articles of Te Tiriti o Waitangi to assess te Tiriti compliance of the regulated competency documents. Overwhelmingly the study found that existing professional competency documents were ‘not yet fit for purpose as frameworks for upholding te Tiriti’ (Came et al., 2021: p.38). Therefore, the future design and delivery of health professional education programs in Aotearoa New Zealand must incorporate Te Tiriti o Waitangi as a living and foundational document and extend this to the lived experience of Māori. Paying genuine attention requires all health professionals to step outside of the prevailing western-based understandings of health and approaches to education.

Curricula changes are apparent in the education of health professionals in Aotearoa New Zealand including deliberate attempts to integrate service-user perspectives and te Tiriti, indigenous and Māori perspectives. Analyses of the success of these suggest that they remain inadequately addressed (Pitama et al., 2018). Internationally, the need to acknowledge indigenous ways of knowing and include them in curricula to address inequity and disparity has been realised (Fildes et al., 2021; Jones et al., 2019).

Current challenges to enable this include the requirement of clinical practices hours by some RAs and how these are defined in the development of the individual discipline. Restrictions on student progress through programs, such as requirements that education providers seek permission of an RA for a student to repeat a course component, are another example of the inflexibility and the degree of control within the current approach to course accreditation and monitoring.

An educationally informed evaluation of curricula, clinical learning and student pathways would focus on the learning and competence of students. The opportunity to create more flexible routes to professional registration and practice could result in a graduate from one discipline completing an additional and shorter period of learning and assessment in another related field to gain an additional registration. This would have the added benefit of valuing extended and advanced practice as a career pathway. Some ‘double degrees’ such as paramedicine and nursing have evolved in response to the need for a more flexible workforce that provides a wider range of care (Plummer et al., 2017), including their practical skills, and ability for creative planning and communication in a variety of clinical situations (Lee, 2020).

Redesigning curricula so that the final year of study is a ‘capstone’, would incorporate the highest level of skill and practice development for the beginning practitioner, and the associated teachers’ strengths required for capstone design, such as assessment skills, experience and their continued connection to the health industry, and ability to work across faculties (Howe and Rosenbauer, 2017). The current graduate entry masters-level qualifications into nursing (Macdiarmid et al., 2021) and physiotherapy are good examples of how traditional approaches that individual professional registrations require separate 3 or 4-year undergraduate degrees can be re-envisaged.

Health professionals and graduates

The need for flexibility within the health and disability workforce is referenced by the World Health Organization (WHO) in its work on interprofessional learning and collaborative practice more than a decade ago (World Health Organisation, 2010). Recognition of similarities across professions (knowledge, skills, cultural safety, professional practice) and the benefits of sharing expertise and care to provide better access and outcomes (Jones et al., 2014) formed the basis of shared and common curricula elements at the Auckland University of Technology. It is common for students in health professional programs to spend time learning with, and about those enrolled in other courses of study.

The increasing recognition of the need for potential new and blended scopes of practice has not been served well by traditional approaches to workforce planning. In recent times, workforce planning in the health sector has focussed on projects relating to resources and service delivery requested by the employers (Rees, 2019). Quantitative approaches to analysing services and predicting staffing numbers are more likely to replicate existing roles and skillsets than enable new and innovative opportunities for defining services and practice. Simple approaches to workforce planning consider historical numbers within individual groups of practitioners without necessarily referencing future needs (Rees et al., 2020).

The regulation of professions through distinct RAs increases a sense of individualism and effectively creates silos which potentially work against the benefits of shared learning and practice (Shaw and Tudor, 2021). To date the approach to pre-qualifying curricula incorporates limited interprofessional learning. However, the most recent amendment to the Health Professionals Competence Assurance Act (2019) specifically references opportunities to learn and practice across professional boundaries by adding a function for RAs: ‘to promote and facilitate inter-disciplinary collaboration and co-operation in the delivery of health services’ (Health Professionals Competence Assurance Act, 2019, §37(3)).

Regulatory frameworks are formal and bureaucratic, arguably affording professions more power than service users (Fraher and Brandt, 2019), nevertheless interprofessional learning and service user-centred approaches to curricula development and design have the potential to emphasise service users, their experiences and outcomes. Other jurisdictions have established models that enable collaboration between regulatory agencies (Bogossian and Craven, 2020; Lahey and Fierlbeck, 2016; Leslie et al., 2018).

Additional scopes of practice have the potential to extend and enhance the service that can be delivered to communities. Postgraduate study currently emphasises research-based learning outcomes and the production of research (Bosch and Casadevall, 2017) but there is no reason why professional development could not include an extension of skillsets and recognition across professional boundaries.

Discussion

This section problematises the impact on the existing design of health professional curricula (by educational institutions) of the requirements for healthcare professional registration (by Responsible Authorities). Discussion focuses on the tensions between attesting competencies including soft skills which can arise from attitudes, beliefs and insight (Vernon et al., 2018) and mandatory technical skills, both of which are required to address improved healthcare provision within Aotearoa New Zealand. A process to inform curriculum change is therefore outlined.

Aotearoa New Zealand has a diverse and dynamic community of healthcare professionals whose education needs to genuinely reflect Te Tiriti o Waitangi and demonstrate an understanding of cultural safety as well as an appreciation of the issues our multi-cultural population face. In order to accomplish this outcome, we need people (we suggest graduates) who are working in the health and disability sector to engage in inter-disciplinary settings and across traditional boundaries (Health and Disability System Review, 2020). We need healthcare professionals to be multiskilled, adaptable and able to innovate and respond. Service user-centred practice should be at the heart of the services provided by health service professionals. Therefore, hearing the voices of communities and the people using services is essential to making meaningful progress. The Health Futures project envisages that by changing the content and process of curricula these issues could be addressed.

We believe there are opportunities to redesign curricula to enable graduates from one profession to complete the final capstone year in another related program and gain additional professional recognition (and registration). More expeditious routes through programs to registered practice can be identified by mapping competencies across programs and resolving critical questions about the detailed requirements of regulators. Changes to the structure of curricula could enable a more multiskilled and flexible workforce that could be responsive to society’s needs. In order for this to occur, Regulatory Authorities would need to reconsider their policies that result in highly prescriptive compliance required in each health professional discipline, including clinical practice hours.

The existing curricula and requirements for practitioners by Regulatory Authorities already appear to reference service user needs and expectations under Te Tiriti o Waitangi. As previously discussed, the majority of frameworks from the Regulatory Authorities with respect to the articles in Te Tiriti were not compliant (Came et al., 2020). This and other issues addressed in the Health Futures project are most easily seen at the point of inequitable experiences and outcomes. Shaw and Tudor (2021) suggest that a lack of educational expertise on the part of the Regulatory Authorities has contributed to a focus primarily on distinct skills and competencies required for each profession and not on complementary skills and competencies that could be utilised across professions. Measuring what we cannot see is difficult. Meaningful elements of interactions with service users, that make a difference for them, such as cultural skills (Jongen et al., 2018), are very difficult to quantify. However, good educational design and practice at undergraduate level could alleviate this concern.

Listening and responding to the community

The action research project involves at least three iterations of conversations with community groups, specifically Māori and service users. Dialogue with the other stakeholders also informs the project. The process is iterative, consultative and facilitative. We value expertise, engagement and honesty. We also take an investigative approach because we want to learn and contribute to the wider community of health professional education developers, teachers and practitioners. For this reason, we will seek consent from those interacting with us to potentially use unidentifiable information as we document and publish information about the process, our learnings and results.

Sharing and evolving

The project team is committed to learning from existing knowledge and expertise, reflecting on the journey itself and sharing what we learn with others. An action research methodology enables participatory research, emphasising reflection and reflexivity. Action research provides an iterative framework and has previously been used to consider indigenous curricula in health professional education (Wilson et al., 2020). The project aims to create a pilot curriculum which will provide an opportunity to embed an evaluative approach, focussing on collaboration and real-world context. It is envisaged that this pilot curriculum will ensure that the competencies of graduating students will meet the requirements of both the educational institution and the Regulatory Authorities, demonstrating that collaborative practice is both iterative and organic.

Process considerations

With its strength in health professional education in Aotearoa New Zealand, including a team of health professional education experts, a range of active curricula initiatives and an extensive curriculum database (Shaw and Donaldson, 2020), Auckland University of Technology is well positioned to consider workforce education and community voice in relation to a range of regulated health professional disciplines. We acknowledge along with Wellings et al. (2017) that it is much more difficult to measure the result of an educational intervention on service user experience or outcome, hence the importance of embedding te Tiriti and generic competencies within an undergraduate program. We intend to listen and respond to all our identified communities as we share and evolve our project.

Re-envisaging the content, process and structure of curricula (an aim of the Health Futures project) has the potential to bring about enduring and meaningful change in the workforce and delivery of healthcare and disability support in Aotearoa New Zealand. This project has been developed in consultation with educators, Māori community, sector experts and discipline leaders, alongside conversation with the Tertiary Education Commission and Ministry of Health.

Conclusion

This action research study provides a springboard for all stakeholders to participate in addressing issues (both policy and practical) in the educational preparation of health practitioners. Equity in healthcare in Aotearoa New Zealand is valued but not yet achieved. Hence, a sector review was undertaken and demonstrated the complexity of the problem of inequity amongst service users in access to healthcare and in resultant outcomes. The review highlighted the need for stakeholders to work together to improve healthcare provision. The active involvement of stakeholders in our study (inherent in action research) brings the very real potential to contribute towards meeting the goals of service users, educational providers and the healthcare workforce. Importantly, Vision Mātauranga provides a new way of considering equity to create a better future. Uniting the two frameworks of Vision Mātauranga and action research can offer a way of reducing the complexity of the problem by creating a more cohesive understanding and solutions to the issues in the education of health professionals.

This paper contributes to policy discussions related to enabling graduating health professionals to be better equipped to implement change in the healthcare system. Our motivation is focussed on re-envisaging the way we educate health professionals to reflect the many voices in Aotearoa New Zealand. The ultimate goals are twofold: (1) to bring about positive change in what is taught and how it is taught, with potential to transform the practice of graduates for the changing environment and (2) to provide flexible routes to qualification and registration, which has the potential to extend the scope of practice for health professionals. This in turn can expand both the range of and access to healthcare services for the whole population.

Footnotes

Acknowledgement

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by Auckland University of Technology Health Futures.

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by Auckland University of Technology, New Zealand (Health Futures R12189).

ORCID iDs

Susan Shaw

Katharine Hoskyn

Susan Shaw has a background in education and health care having originally qualified as a primary school teacher and then a nurse. She has held various academic leadership roles since joining Auckland University of Technology in 1992. Her commitment and contribution to educational practice been recognised with the award of a Principal Fellowship from the Higher Education Academy. She has maintained clinical interest and practice in the areas of disability and palliative care; has co-edited five textbooks with Oxford University Press and continues to teach undergraduate and postgraduate students. Susan has served as the Associate Dean (Academic) in the Faculty of Health and Environmental Sciences and a Director of the National Centre for Interprofessional Education and Collaborative Practice at AUT.

Denise Atkins is a Senior Lecturer and Academic Development Advisor in the Faculty of Health and Environmental Sciences at AUT University. She is a Senior Fellow of the Higher Education Academy (UK), a member of the AUT Academy (2019) and a recipient of the Vice Chancellor’s Excellence in Teaching award (2016) and undertakes research in the fields of Teaching and Learning, Health and Physical Education, higher education, pedagogy, play and children’s voice. As a previous senior advisor with the Ministry of Education, Denise worked in partnership with a range of government agencies with a focus on young people’s wellbeing. Denise has had experience leading and managing teams and has considerable governance experience. Her expertise lies in working both with Boards and Management, as well as with teachers and academics in professional learning and teaching using evidence-based research.

Katharine Hoskyn’s family are of Cornish, Scottish and Yorkshire descent. Her ancestors include a Scot who was beheaded for leading an uprising against the King of England and farmers who were displaced during the Scottish Highland clearances when animal farming was introduced to an arable part of Scotland. After 15 years in the market research and food industries, Katharine joined Auckland University of Technology (AUT) as a lecturer and supervisor of work-integrated learning students. She has been passionately involved in Work-Integrated Learning in leadership, co-ordination and supervising roles, with considerable experience in the development, co-ordination and management of WIL programmes at AUT, as well as marketing papers. This included involvement in the organisation of papers for conjoint students taking business in conjunction with arts, sport, social science, psychology, hospitality and environmental science. Her wide-ranging research interests are focussed on not-for-profit communities.

Todd Stretton is a Physiotherapy Lecturer (2007-present) and Faculty Academic Quality and Development Advisor at AUT University, Auckland, New Zealand (2020-present). He has a passion for technology-enhanced learning which has been acknowledged in receiving both the Faculty and Vice-Chancellor’s Award for Teaching Excellence (Teaching Innovation) in 2019. Todd is currently enrolled in his PhD at the University of Melbourne, investigating the impact of immersive reality for critical thinking in healthcare higher education (education design research). He is an active member of the Scholarship of Technology Enabled Learning research cluster (http://sotel.nz), the Interprofessional Steering Group, and has co-leads the Virtual Learning Space project at AUT’s North Campus. Todd regularly reviews international physiotherapy curriculum for the New Zealand Physiotherapy Board and has an active role in AUT’s Articulation Agreement with Namseoul University, South Korea. He is a current member of the UK based Association for Learning Technology (CMALT), and the Australasian Society of Computers in Learning in Tertiary Education (). Previous roles include Physiotherapy Programme Leader - Curriculum, Chair of the Neurology Special Interest Group (NSIG) for Physiotherapy New Zealand (PNZ) (2013–2018), and Senior Research Officer at AUT University.

Helen Hamer is an independent nurse consultant with extensive years of clinical experience, teaching, supervision, and leadership in the consumer-clinician alliance to promote research that directly informs clinical practice. Helen has been with the New Zealand College of Mental Health Nurses since its inception, she is a Fellow of the College and an active member of the Auckland branch. Helen’s research interests are in social justice, rights, inclusion and citizenship, and supporting the development of mental health nurses’ practice to offer a rights based approach for the people we serve. Helen holds an honorary academic position at Yale University, USA where she conducts research and teaching within the Department of Psychiatry’s centre for recovery and citizenship studies. Helen has experience in leading systems change to support the skills-base of all staff in the use of talking therapy and work more closely with primary care settings.

References

Ahuriri-Driscoll

Lee

Came

(2021) Amplifying Indigenous voice and curriculum within the public health academy–the emergence of Indigenous sovereign leadership in public health education. Higher Education Research and Development 40(1): 146–161.

Akmal

Gauld

(2021) What components are important for effective healthcare alliance governance? Findings from a modified delphi study in New Zealand. Health Policy 125: 239–245.

Alford

Head

(2017) Wicked and less wicked problems: a typology and a contingency framework. Policy and Society 36: 397–413. DOI: 10.1111/j.1540-6210.2007.00866.x

Al-Busaidi

Huria

Pitama

et al. (2018) Māori Indigenous health framework in action: addressing ethnic disparities in healthcare. The New Zealand Medical Journal 131(1470): 89–93.

Bogossian

Craven

(2020) A review of the requirements for interprofessional education and interprofessional collaboration in accreditation and practice standards for health professionals in Australia. Journal of Interprofessional Care 35: 691–700.

Bosch

Casadevall

(2017) Graduate biomedical science education needs a new philosophy. MBio 8(6): e01539–17. DOI: 10.1128/mBio.01539-17

Bradbury

(ed), (2015) The Handbook of Action Research. 3rd edition. Thousand Oaks, CA: Sage.

Bradbury

Lewis

Embury

(2019a) Education action research. The Wiley handbook of action research in education.Hoboken. NY: Wiley Blackwell Publications. Craig Mertler, 17(4), 71.

Bradbury

Waddell

O’Brien

, et al. (2019b) A call to action research for transformations: the times demand it. Action Research 17(1): 3–10.

10.

Broadbent

(2022) Watershed health reforms aim to transform services. ANZCA Bulletin 31(1): 14–15.

11.

Brown

Bryder

(2023) Universal healthcare for all? Māori health inequalities in Aotearoa New Zealand (1975)–2000. Social Science and Medicine 319: 115315. DOI: 10.1016/j.socscimed.2022.115315

12.

Came

Kidd

Heke

, et al. (2021) Te Tiriti o Waitangi compliance in regulated health practitioner competency documents in Aotearoa. The New Zealand Medical Journal 134(1535): 35–43.

13.

Came

O’Sullivan

Kidd

, et al. (2020) The Waitangi Tribunal’s WAI 2575 report: implications for decolonizing health systems. Health and Human Rights 22(1): 209–220.

14.

Classen

Tudor

Johnson

, et al. (2021) Embedding lived experience expertise across the mental health tertiary education sector: an integrative review in the context of Aotearoa New Zealand. Journal of Psychiatric and Mental Health Nursing 28: 1140–1152. DOI: 10.1111/jpm.12756

15.

Coghlan

(2019) Doing Action Research in Your Own Organization. 5th edition. Thousand Oaks, CA: Sage.

16.

Curtis

Jones

Tipene-Leach

, et al. (2019) Why cultural safety rather than cultural competency is required to achieve health equity: a literature review and recommended definition. International Journal for Equity in Health 18(1): 1–17.

17.

Dean

Eady

Yanamandram

(2020) Advancing Non-placement Work-Integrated Learning across the Degree [Special Issue]. 4th ed. Journal of University Teaching and Learning Practice, 17, 1.

18.

Dijk

Duijzer

Wienold

(2020) Role of active patient involvement in undergraduate medical education: a systematic review. BMJ open 10(7): e037217. DOI: 10.1136/bmjopen-2020-037217

19.

Edwards

(2009) Titiro Whakakuri Kia Marama Ai Te Wao Nei: Whakapapa Epistemologies and Maniapoto Māori Cultural Identities. Palmerston North: Massey University.

20.

Elliot

Cloet

(2017) People's mental health report. https://static1.squarespace.com/static/58f48f2459cc680bc7a237aa/t/58f5d384b8a79b4768cb93a8/1492505610169/PMHR+%2528FINAL%2529.pdf

21.

Ferdinand

Lambert

Trad

, et al. (2020) Indigenous engagement in health: lessons from Brazil, Chile, Australia and New Zealand. International Journal for Equity in Health 19(1): 1–12.

22.

Fildes

Beck

Bur

, et al. (2021) The first steps on the journey towards curriculum reconciliation in science, medicine and health education. Higher Education Research and Development 40(1): 194–206.

23.

Fraher

Brandt

(2019) Toward a system where workforce planning and interprofessional practice and education are designed around patients and populations not professions. Journal of Interprofessional Care 33(4): 389–397.

24.

Garrod

(2019) Globalization and the future of Canada’s Medicare identity: a longer view. Journal of Canadian Studies 53(2): 197–237.

25.

Goodyear-Smith

Ashton

(2019) New Zealand health system: universalism struggles with persisting inequities. Lancet (London, England) 394(10196): 432–442.

26.

Happell

Byrne

McAllister

, et al. (2014) Consumer involvement in the tertiary-level education of mental health professionals: a systematic review. International Journal of Mental Health Nursing 23(1): 3–16. doi: 10.1111/inm.12021. Available at: https://doi.org/10.1111/inm.12021.

27.

Health and Disability System Review (2020) Health and Disability System Review – Final Report – Pūrongo Whakamutunga. Wellington: HDSR.

28.

Hiam

Orcutt

Yates

(2019) Universal health coverage in the UK. BMJ (Clinical research ed.);367, l7054. doi: 10.1136/bmj.l7054

29.

Hobbs

Ahuriri-Driscoll

Marek

, et al. (2019) Reducing health inequity for Māori people in New Zealand. Lancet (London, England) 394(10209): 1613–1614.

30.

Howe

Rosenbauer

L-M

(2017) Extending the 2015 Capstone Design Survey: data from Australia and New Zealand. Engineering: Faculty Publications.

31.

Jones

McCallin

Shaw

(2014) Reflections from New Zealand: facilitating cultural Change. In: Leadership Development for Interprofessional Education and Collaborative Practice. London: Palgrave Macmillan, pp. 179–195.

32.

Jones

Crowshoe

Reid

, et al. (2019) Educating for indigenous health equity: an international consensus statement. Academic medicine: Journal of the Association of American Medical Colleges 94(4): 512–519.

33.

Jongen

McCalman

Bainbridge

(2018) Health workforce cultural competency interventions: a systematic scoping review. BMC Health Services Research 18(1): 1–15.

34.

(2019) Kypros Nicolaides, World Expert in Fetal Medicine: “we Must Keep Asking Ourselves Whether we’re Doing The Right Thing”. https://nieuws.kuleuven.be/en/content/2019/patronsaintsday-kypros-nicolaides. Retrieved 7 January 2021.

35.

Lahey

Fierlbeck

(2016) Legislating collaborative self-regulation in Canada: a comparative policy analysis. Journal of Interprofessional Care 30(2): 211–216.

36.

Lee

S-H

Bajracharya

Min

, et al. (2020) Strategic approaches for colon targeted drug delivery: an overview of recent advancements. Pharmaceutics 12(3): 68–74. DOI: 10.33615/jkohs.2020.8.3.68

37.

Leslie

Nelson

Deber

, et al. (2018) Policy tensions in regulatory reform: changes to regulation of health professions in Australia, the United Kingdom, and Ontario, Canada. Journal of Nursing Regulation 8(4): 32–42.

38.

Macdiarmid

Winnington

Cochrane

, et al. (2021) Using educational design research to develop authentic learning for Graduate Entry Nursing students in New Zealand. Nurse Education in Practice 51: 102965. DOI: 10.1016/j.nepr.2021.102965

39.

McKenna

(2020) Cultural safety: there is no turning back. Journal of Psychiatric and Mental Health Nursing 27(5): 495–496.

40.

Ministry of Health (2020) Whakamaua: Māori Health Action Plan 2020–2025. Wellington: Ministry of Health.

41.

Ministry of Research Science and Technology (2007) Vision Matauranga: Unlocking the Innovative Potential of Maori Knowledge, Resources and People. Wellington: Ministry of Research, Science and Technology. https://www.royalsociety.org.nz/assets/Uploads/Vision-Matauranga-document-2007.pdf

42.

New Zealand Government (2022) Future of Health. Wellington: Department of the Prime Minister and Cabinet. https://www.futureofhealth.govt.nz/maori-health-authority/

43.

Palmer

Gray

Huria

, et al. (2019) Reported Māori consumer experiences of health systems and programs in qualitative research: a systematic review with meta-synthesis. International Journal for Equity in Health 18(1): 1–12.

44.

Pitama

Palmer

Huria

, et al. (2018) Implementation and impact of indigenous health curricula: a systematic review. Medical Education 52(9): 898–909.

45.

Plummer

Tozer-Jones

Williams

(2017) The Bachelor of Nursing/Bachelor of Emergency Health (paramedic) degree: how well does it align with course objectives? Australasian Journal of Paramedicine 14(4): 1–8.

46.

Ramsden

(1993) Cultural safety in nursing education in Aotearoa (New Zealand). Nursing Praxis in New Zealand inc 8(3): 4–10.

47.

Rees

(2019) The evolution of New Zealand’s health workforce policy and planning system: a study of workforce governance and health reform. Human Resources for Health 17(1): 1–9.

48.

Rees

Crampton

Gauld

et al. (2020) Rethinking workforce planning for integrated care: using scenario analysis to facilitate policy development. BMC Health Services Research 20: 1–12.

49.

Reid

Cormack

Paine

(2019) Colonial histories, racism and health—the experience of Māori and Indigenous peoples. Public Health 172: 119–124.

50.

Shaw

Donaldson

(2020) A detailed analysis of quality improvement and patient safety within undergraduate health professional curricula in Aotearoa New Zealand. The New Zealand Medical Journal 133(1518): 19–32.

51.

Shaw

Tudor

(2021) Health(y) education: a critical analysis of the role of public health regulation in and on tertiary education in Aotearoa New Zealand. Policy Futures in Education 19: 907–924.

52.

Taylor

(2022) The Pae Ora healthy futures bill and health reforms. New Zealand Journal of Medical Laboratory Science 76(2): 96.

53.

Vernon

Chiarella

Papps

(2018) Investigating the relationship between continuing competence and insight in nursing and midwifery practice. Journal of Nursing Regulation 9(3): 36–52.

54.

Waddock

Meszoely

Waddell

, et al. (2015) The complexity of wicked problems in large scale change. Journal of Organizational Change Management 28(6): 993–1012. DOI: 10.1108/jocm-08-2014-0146

55.

Wailling

Marshall

Wilkinson

(2019) Hearing and responding to the stories of survivors of surgical mesh: Ngā kōrero a ngā mōrehu – heurupare (A report for the Ministry of Health). In: The Diana Unwin Chair in Restorative Justice. Wellington, New Zealand: Victoria University of Wellington.

56.

Wellings

Gendek

Gallagher

(2017) Evaluating continuing nursing education: a qualitative study of intention to change practice and perceived barriers to knowledge translation. Journal for Nurses in Professional Development 33(6): 281–286.

57.

Wepa

Wilson

(2019) Struggling to be involved: an interprofessional approach to examine Māori whānau engagement with healthcare services. Journal of Nursing Research and Practice 03(3): 1–5.

58.

Wilson

Heinrich

Heidari

, et al. (2020) Action research to implement an Indigenous health curriculum framework. Nurse Education Today 91: 104464. DOI: 10.1016/j.nedt.2020.104464

59.

World Health Organization (2010) Framework for Action on Interprofessional Education and Collaborative Practice. https://www.who.int/hrh/resources/framework_action/en/.Retrieved from 7 February 2021.

60.

Legal statutes

61.

Health Practitioners Competence Assurance Act 2003

62.

Health Practitioners Competence Assurance Amendment Act 2019

Enabling action: Re-envisaging education of health professionals in Aotearoa New Zealand

Abstract

Keywords

Introduction

Setting the scene

Frameworks

Complexity of the problem

Vision Mātauranga

Action research

Stakeholders

Māori community and wellbeing

Lived experience of the users of health services

Education and health sector: current curricula

Health professionals and graduates

Discussion

Listening and responding to the community

Sharing and evolving

Process considerations

Conclusion

Footnotes

Acknowledgement

Declaration of conflicting interests

Funding

ORCID iDs

References