Cultural competency in doctor-patient communication has developed as part of broader strategies to address disparities in health care for minority ethnic groups.1
While most doctors engage with patients with positive intent, there is evidence that misperception and lack of connection between patients from non-dominant ethnic groups and medical professional is not uncommon.2,3 Poor engagement between doctors and patients is associated with negative outcomes for both the patients4 and doctors.5
How cultural competence is best taught and implemented in clinical settings remains uncertain. Initially medical education focused more on providing cultural information, with limited attention being paid to the application of this information to a specific clinical context.6,7 How to integrate ethnic cultural beliefs, values and practices into clinical practice has rarely been made explicit. This is particularly problematic where elements of an ethnic culture and medical culture are incompatible or even in direct conflict.8
There have been some attempts internationally to guide clinicians in engagement strategies with some ethnic groups.9 An alternative approach has been to produce generic non ethnic-specific guidelines although these have not been considered within New Zealand medical context.10
There has been extensive work within the area of Māori health regarding the importance of Māori culture in the New Zealand health system 11, and some training options exist for enhancing clinician’s ability to work effectively with Māori 12, 13. However the routine adoption of Māori cultural competency as a core clinical skill and the best method for teaching and learning these skills is still to be agreed.
In this paper we present the ‘Hui Process’ as a framework for working effectively with Māori that is currently taught in the University of Otago, Christchurch.
The University of Otago hosts a six-year undergraduate medical training course. Hauora Māori is included within the medical curriculum as a vertical module throughout each year of the course. The Hauora Māori curriculum encompasses the breadth of learning environments with immersed, integrated and independent learning.
The ‘Hui Process’ was initially piloted in the advance learning in medicine years (Years 4–6) at the University of Otago, Christchurch campus, and has also been applied at other clinical sites.
Medical students are introduced to the ‘Hui Process’ in an immersed marae (traditional meeting place) setting at the beginning of 4th year and skills are further developed during subsequent clinical rotations.
A hui is a meeting or coming together and is a central ritual of encounter in Te Ao Māori (The Māori world).14 The authors acknowledge drawing on traditional knowledge and practice and aligning it to a contemporary situation in seeking to develop more culturally congruent practice with Māori patients and whānau (family and support network).
The ‘Hui Process’ applies traditional principles of greeting, introducing, starting a relationship and closure of an encounter to the setting of a medical consultation. These principles may be observed overtly in powhiri (formal structured meetings), and can also be seen to occur with more subtlety in informal meetings.
The ‘Hui Process’ has been explicitly aligned with the University of Otago’s standard teaching model for clinical interviewing (the Calgary-Cambridge framework).15
The ‘Hui Process’ has been identified as containing four key elements: Mihi, Whakawhānaungatanga, Kaupapa and Poroporoaki, as described below:
- Mihi: initial greeting and engagement.
- Application to clinical consultation: The main focus of the first stage is to ensure clinicians clearly introduce themselves and describe their role (as the doctor) and the specific purpose of the consultation to the Māori patient and whānau. At this stage, the clinician should also confirm that the patient identifies as Māori.
- Whakawhānaungatanga: making a connection.
- Application to clinical consultation: The primary focus of this stage is connecting at a personal level with the patient and any whānau present. This process is based on a traditional format of engagement within Māori cultural protocol, and is often mistaken as ‘building rapport’.
Building rapport is important and is a usual step with all patients, however engagement with Māori patients and whānau requires a further step. Whakawhānaungatanga requires clinicians to draw on their understanding of Te Ao Māori and relevant patient and whānau Māori beliefs, values and experiences 16. This may be in terms of the patient’s whenua (land) connections, whānau involvements, use of te reo (Māori language) 17. This should not only include identification of these aspects of the Māori patient, but critically should include some self-disclosure of the student / doctor about their own experience of these aspects.
At times it may not be fruitful to pursue the medical agenda until this point of shared experience is reached. This is a key point of difference from existing clinical skills teaching and something established clinicians may consider challenging where no self-disclosure has been taught, often as part of establishing boundaries. Similar boundaries exist within Te Ao Māori and the ‘Hui Process’ and obviously limits of self-disclosure must be considered. The challenge for the teaching staff has been to help students identify appropriate information that will assist them in moving from rapport to whakawhānaungatanga with Māori patients, while remaining within safe boundaries.
We observed that medical students coming to New Zealand from other countries had fewer problems adopting this new approach compared to students who grew up in New Zealand. It is often noticeable when a connection has been made, for example, as indicated by the patient asking personal questions, change in body posture, or use of humour.
It is emphasised that whakawhānaungatanga is not a one off event and there is a need to attend to connecting with the patient and whānau throughout the consultation.
- Kaupapa: attending to the main purpose of the encounter.
- Application to clinical consultation: this is identified as the point at which the focus moves to history taking or whatever the clinical task at hand is (e.g. taking blood pressure). Students are provided with a complementary framework, the Meihana Model,16 to extend the standard history taking process presented elsewhere.
The Meihana Model has undergone development to incorporate aspects of further contemporary and historical factors that may influence the health experience of patients and whānau such as migration, colonisation, racism, marginalisation and Māori beliefs, values and experiences. This allows for a broader focus in understanding patients’ presenting complaints, as well as facilitating ongoing whakawhānaungatanga as patients are encouraged to talk more broadly about their situation.
- Poroporoaki: concluding the encounter.
- Application to clinical consultation: thisreminds the students of the need to clearly identify both the finishing point of the consultation and to ensure clarity about the next steps for the patient and whānau.
Three tasks are identified:
- Ensure that you have understood what the patient has said,
- Ensure the patient understands what you have said, and
- Ensure the patient is clear about the next steps (for example the date for a follow-up appointment, details of referral for tests, lifestyle change, medication regimes etc).
Research exploring Māori patient and whānau experience within the health system highlights that this process is often seen as sub-optimal and incomplete.2 The poroporoaki only occurs if a relationship has been effectively developed over the consultation as the traditional role of the poroporoaki was to ensure all ‘business’ of the hui was completed, that both parties understood what would come next, and that the relationship existed for further steps to be negotiated as required. The aim of this stage is to provide students with the tools to articulate a poroporoaki process which is comfortable and appropriate with Māori patients and whānau.
The hui process is usually introduced to students based on initial engagement with a Māori patient and whānau. Subsequent meetings follow a similar but more abbreviated format and may simply reflect upon the shared commonality identified in whakawhānaungatanga stage on the previous occasion as well as the outcome of the last meeting.
Students are firstly introduced to the ‘Hui Process’ through the use of simulated patients, using role-play techniques in a group format. Students also view videos where a clinician is modelling the ‘Hui Process’. Students are then encouraged to utilise the ‘Hui Process’ with Māori patients they encounter across all clinical rotations.
The students then undertake summative assessments which require the ability to utilise the ‘Hui Process’ with a Māori patient for their Hauora Māori written long case and their Hauora Māori oral case presentation. There is an additional opportunity to assess students’ use of the ‘Hui Process’ during the Hauora Māori OSCE. A review of students’ performances in these summative assessments identifies that the students are able to apply the ‘Hui Process’ and its core principles to clinical settings.
Evaluation of the ‘Hui Process’, including formal student feedback and observation of student performance on summative assessments, suggests students value having a specific framework (which involves specific lines of questioning and guided questions) to work with, as they develop their history taking skills. Student feedback suggests that the teaching process and the framework itself are seen as acceptable and relevant. Further systematic evaluation of the ‘Hui Process’ is underway.
Self-reflective comments from students has also revealed that a number of students become aware of the impact of not using the ‘Hui Process’, and recognised better engagement with patients and better quality information when using the process.
One student identified being able to more clearly identify the nature of a presenting problem and making an appropriate referral for input from a Māori Health Worker, once she had engaged in the “Hui Process”. There has also been some informal feedback from community members reporting increased engagement and satisfaction by patients involved in ‘Hui Process’ consultations.
While evaluations are still in the early stages and limited conclusions can be drawn, it seems that the “Hui Process” meets requirements as an effective cultural competence framework. It is firmly grounded in the culture of the target group, it aligns well with standard medical practice and is seen as relevant and useful by students. Most importantly it appears that it can be applied by students and has a positive impact on patient experience.
It is a challenge to develop and teach cultural competence which extends beyond tokenistic or oversimplified stereotypes and truly integrates clinical and cultural elements of practice. Teaching cultural competency in a way which facilitates application of knowledge in clinical practice in ways which reflect patient reality remains a challenge.
Identifying the relevance of such competencies to ‘real’ medicine remains critical, as does ensuring that the skills applied are relevant to patients. While the initial development and evaluation of the ‘Hui Process‘ suggests that this cultural competence fulfils many of the criteria for effectiveness, the full impact of this teaching on both student practice and patient experience has yet to be assessed.
We present a simple framework for enhancing the therapeutic relationship between clinicians and Māori currently taught at the University of Otago. Initial feedback indicates it is found to be effective by students and well received by Māori. Students have also identified that their use of the ‘Hui Process’ has sometimes assisted in improving the therapeutic relationship between more senior clinicians and Māori patients.
We encourage all clinicians, irrespective of their discipline or level of training, to consider adopting the ‘Hui Process’ with Māori patients. While cultural competence is important for all, we caution against the use of this approach for other cultural groups. The essential element of this framework is its alignment with Te Ao Māori principles and exclusion of these may result in similar non-ethnic specific guidelines already available 10. However the process of integrating culturally specific principles of greeting and relationship building to the medical consultation could be applied by other cultural groups.
It is hoped that adoption of this framework is one strategy that individual clinicians can adopt which may result in improved health outcomes for Māori and the closure of the gap in life expectancies with non-Māori. The potential impact of this framework was suggested by a community member who presented with a range of health challenges and had been a high user of health services for over thirty years.
This person provided unsolicited feedback to one of the authors after being interviewed by a 4th-year student who used the ‘Hui Process’:
Ultimately the effectiveness of the learning cultural competency is reflected in the quality of the relationships established and the fruits of those relationships, in terms of connections, understandings, and the willingness to engage and to trust.