‘Mana’ and ‘manaaki’

The term ‘mana’ means prestige, control, authority, status, and spiritual power - it is a supernatural force in people and objects. Everything has mana. To ‘manaaki’ means to take care of people, ensuring they can reach their potential by supporting them and by showing them respect. Manaaki has a reciprocal element as sincere relationships are mutually beneficial and have interactive exchanges that help to lift the esteem and potential of others. Manaakitanga is the process of actively caring for people, providing hospitality, and showing kindness and generosity. Whānau in the Pae Herenga study highlighted in their pūrākau (stories) that health professionals can become an important participant of the whānau care system – they have an integral health care role to play.

Being part of the extended whānau

Health professionals bring their own skills and experiences to the whānau partnership. In our Pae Herenga study, we heard many stories about health professionals showing kindness, understanding, and taking the time to listen to whānau. Going the extra mile signals to whānau your willingness to walk alongside them while adding to their kete (basket) of knowledge. Your willingness to develop strong and trusting relationships with whānau, on a whānau-by-whānau basis, is appreciated; it can help to open the health organisation’s door to whānau.

The professional support that health and social care professionals provide can helpfully assist whānau to move through the challenges that can accompany the journey through Te Pō (changes and transformations). Joining with whānau means becoming an important part of the whānau manaaki partnership. When health and social care professionals appreciate their own identity, cultural values and spiritual beliefs they are in a better position to respect and care for the cultural aspirations and needs of older Māori and their whānau. We promote a standard of care that that respects and protects the values and customs of Māori people which are protected under the Treaty of Waitangi (1840). Establishing partnerships with whānau is important and critical to good end of life care. Whaea Linda (hospice kaiwhakahaere) talks about the importance of getting to know whānau, spending time with them so they feel comfortable to talk and share what they need:

Well, the first thing you have to do really which I think I’m pretty good at it, is to get to know the patient, and to see if they really want me to work with them first and foremost. You know. And I don’t like- can’t assume. And even the families, because you can get some really difficult families out there. So, it’s just making [and] building that relationship up with, especially with the patient and the family… they’ve got to be comfortable; they have to be comfortable with me. And I have to be comfortable with them too. If I feel that I’m not comfortable with them, I just say, ‘Look, it’s okay if you don’t [want this] we don’t [have to] come and visit.’ Then next minute they go, ‘Yes please come,’ you know they go by that so.

Matua Hugh (hospice volunteer) describes how his presence can make a difference for Māori whānau when he visits them:

What I have been able to change at hospice? It’s not just the ‘routine boys.’ You know, we’re not just going on a van and we’re going to deliver the bed and the toilet and everything else to this place. It’s not just about that you know. It’s about the people, it’s about the people in the house, it’s about the wairua… I’m a Māori and I’m probably the only Māori lifter driver that’s in our team.

… We’ve gone to pick up a bed from somewhere [from name of place] quite a few times. We’ve been down there you know, and you get down to our whanaunga’s [relative’s] whare [house] who had buried, it would be the wife in this case, you know - very solemn. And you know she’s hurting; the husband’s passed away and they’ve gone through all this hassle of the hui mate [funeral] and all of that. She’s trying to settle back into her whare. So, she sees me as, you know, being another Māori and she [makes a hugging motion] … Oh you know, you can feel that - that wairua [spiritual connection]. You know the wairua.

While talking about the tikanga and kawa that whānau draw on while using hospice services, Kui (hospice health care assistant) reflected on caring for a Rātana Minister and the approach she used that protected his mana while showering:

We just had a man that was in [hospice]. But he was Rātana and they came to church every night… Sunday they had a big church and they came and had a big feast out in the lounge and then they had their church service and you could hear them singing - it was beautiful. You know it’s like ‘oh, awesome’. And he was a Minister… and he was very like, ‘Kia ora bub.’ And I said, ‘Kia ora.’… I said, ‘Would you like to come with me for a shower?’ ‘No.’ I say, ‘Okay, next time.’ Then the next day, ‘Would you like to come with me for a shower?’ ‘Oh, I suppose.’ I said, ‘Yeah, here’s a towel. You go in there and you can wash yourself, and you can call me’. His wife goes, ‘You know what? That’s the first time he’s let any of his carers give him a shower.’ And I said, ‘Oh wow that’s cool.’

Health and social care professionals who are accepted by whānau are empathic, kind and compassionate. There is no judgement of others. Their aim is to be open and transparent so that any concerns that arise can be openly discussed with the whānau. When issues arise, the health professional can calmly help whānau to work through these changes by sharing their knowledge of the processes and procedures that accompany different situations. Knowing the community and keeping track of who is unwell and who might need support can be very helpful to kaumātua and their whānau at end of life. Joy (health professional) checks the cancer database every morning to familiarise herself with patients coming into hospital. This allows her to keep a watch for Māori patients:

I do have a system every morning I go through at work, like I’ve got a database. I know all the patients who are coming in. And because I work with the faster cancer tracking programme as well and we’ve got a database for that, so I’m always watching out who’s the Māori coming through ah, where they’re at, working with the tumour stream nurses and making [contact] you know, because they will identify patients they think would need support which is just about everyone.

Kaiāwhina, Kaiwhakahaere and Whānau Ora Kaimahi are all terms for Māori support people; they provide a valuable link between health services and whānau in the local community. They usually walk in both worlds and are often mandated and supported by their own communities to do this work. Joy feels it’s important to make patients feel safe. She likes to contact her patients by telephone just before they come in for their oncology appointments. Helping patients feel safe is an important part of her role.

My role is also supporting patients in the oncology unit. So, I always check who’s coming in to see the doctors on the day. If I’ve got some of my patients that are coming through I make sure, or even tell them before they even come over- ‘Look I’ll watch out for your appointment because I work with the booking clerk’. And I make sure, when they’ve got their appointment that I ring them personally to tell them. So, they know. And I tell them where to come. Although it’s a booking clerk role that I do, like an admin role, it’s still a personal role and I think it’s really important. Just to make sure that they’re safe, they feel safe, and that I will meet them there, when they come in.

With up to twenty new patients coming into the hospital each month Joy (health professional) cannot physically visit her rural patients. However, having established strong community connections, she is in a position where she can contact iwi provider nurses and other community services for help. Joy (health professional) highlights the importance of keeping good community connections as she says she cannot do this job on her own:

I still work closely with the iwi provider nurses because I’m the only one in all of the DHB areas. So, I kept those connections because I find I need them to help me out there because there’s lot of whānau sometimes. You know I can’t just get up and go off to [name of distant rural town]. So, I have the [hauora] nurses up there that I can call on… and I say, 'hey can you help me find this whānau?' Especially if they’re already registered with their medical centre because of the Privacy Act and that. So you know, I’m very careful on that aspect... [I rely on the district nursing support]. It’s really important that you know [who to contact] otherwise I just can’t do it on my own.

Māori health workers can be a useful cultural resource. They can help to support health organisations and staff to become culturally safe by demonstrating end of life care aligned with Māori cultural values and customs. Having an understanding and appreciation of the Māori world can strengthen health professionals to better support kaumātua and their whānau. Ensuring that whānau have an opportunity (at an appropriate time following a death) to evaluate their experiences of using the health services is an opportunity to review the level of cultural safety being enacted by health services and health professionals. Whaea S. (health professional) commented on her knowledge of her community and the networks she had within the community. Having a Māori staff member who was well connected to the local community helped whānau to access hospice services:

I think it was… 99 deaths in the 18 months while I was there [at hospice]. And of them… [Māori were at the] low end of death, [about 40%] Māori, but they were quite involved in hospice prior. So that made the big difference… they’d been diagnosed and come to hospice earlier. I found [out] if Māori were diagnosed, (through my own networks)…

So, the usual referral thing would come along, but you know, I would already know about them… because of [of] my whānau out in the community. So, you know, I’d be at a hui or somewhere and they’d say, ‘Oh have you heard so and so [has] got- might have cancer or-,’ you know. And so, prior to the official referral coming into hospice… I’d already know that they were [coming]. And so, I brought that into the secondary care as well. So, I said to my doctors, I said to my colleagues at the hospital, ‘I’m going to tell you that these ones are on the radar. If they come with a diagnosis of cancer that you need to be talking to them about [hospice]...’ And so, we were trying to raise awareness around that.

Recommendations

For health and palliative care services, we recommend:

  • Consulting with Māori Kaiāwhina, Kaiwhakahaere and Whānau Ora Kaimahi can help develop your relationships with local Māori communities. This will support organisations and staff to become more effective team members in the whānau care system. Local Māori staff are often familiar with their communities and can provide good cultural advice as they have established relationships with kaumātua and whānau. Remember to observe manaakitanga (hosting) responsibilities as well as koha (gifts) befitting the occasion.

For health and palliative care professionals, we recommend:

  • Encourage whānau to reflect on their satisfaction with the care they have received. Provide them with a way to safely give their feedback to the organisation and staff as this is a good way to continue to improve the care and support health services and staff provide while recognising the diversity between, and within, whānau.

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