A pūrākau analysis of institutional barriers facing Māori occupational therapy students.

INTRODUCTION: Across Aotearoa (New Zealand), there are chronic shortages of qualified Māori (Indigenous peoples of Aotearoa) health practitioners and systemic ethnic health inequities. This study, focussing on the discipline of occupational therapy, explores Māori graduates' recollections of the institutional barriers that impacted on their study in this field over a 25-year period.
METHODS: This qualitative study interviewed seven Māori occupational therapy graduates using pūrākau-an innovative Māori narrative inquiry method. Pūrākau (stories) were collected in 2018 via kanohi ki te kanohi (face to face) semi-structured interviews. They were analysed using the kaupapa Māori (Māori philosophical) framework of Pū-Rā-Ka-Ū which draws on traditional Māori mātauranga (knowledge).
FINDINGS: The institutional barriers identified were (1) cultural dissonance, (2) cultural (in)competency and (3) the limitations of (Western) pastoral care.
CONCLUSION: This study highlighted how racism is embedded within the Western tertiary education system. To create a safe learning environment for Māori students, tertiary education institutions require a planned approach to address racism within policy, procedures, the curriculum, teaching and professional staff.

Educators of occupational therapy need to be culturally competent, sensitive and aware to teach students.

Education institutions of occupational therapy need to analyse their policies and procedures to include indigenous perspectives.

Indigenous/Māori health courses and papers need to be compulsory for all occupational therapy students.

INTRODUCTION

The colonial health system which supplanted the existing Indigenous health system has failed for decades to deliver equitable health outcomes for whānau (extended family) (Cram et al., 2019). The colonial system has proven ill‐equipped to consistently deliver culturally responsive care to Māori. There is strong evidence to suggest there is systematic and institutional bias and/or racism against Māori at all levels of the health system—from governance, policy, investment patterns and within health practice itself (Waitangi Tribunal, 2019). This experience is echoed in the colonial education system (Hutchings & Lee, 2016; MacDonald, 2018; Simon & Smith, 2001).

Te Tiriti o Waitangi is the power‐sharing agreement negotiated in 1840 between the British Crown and hapū (sub‐tribes) which established the terms and conditions of non‐Māori settlement in Aotearoa. It reaffirmed Māori tino rangatiratanga (absolute authority) and also granted Māori the same rights and privileges as British subjects. Although Te Tiriti remains central to public policy within Aotearoa (Cabinet Office, 2019), the promises made in this treaty have been consistently and relentlessly broken by the Crown in the subsequent 180 years, and institutional racism has been allowed to flourish (Ministerial Advisory Committee on Māori Perspectives on Social Welfare, 1988; Waitangi Tribunal, 2019).

Much health policy and legislation reinforce the importance of this treaty relationship (Ministry of Health, 2016, 2020). The Health Practitioners Competence Assurance Amendment Act 2019 makes it a requirement for all regulated health practitioners to practice in an effective and culturally respectful way, so that Māori have equitable health outcomes. The occupational therapy competencies (Occupational Therapy Board of New Zealand, 2022, p. 2) outline expectations for practice.

Understanding how Te Tiriti affects all our lives is essential for helping people participate in their desired occupation. Such understanding helps you see how systemic and individual issues can breach people's rights and limit their opportunities to participate in their chosen occupations.

Indigenous peoples have a right to access social and health services without discrimination (United Nations, 2007, 2008). State party signatories such as Aotearoa are required to take all necessary steps to ensure this right is progressively realised by Indigenous peoples.

Culture has long been recognised as a critical determinant of Indigenous health (Durie, 1998). Indigenous health practitioners play an important role in the health sector bringing dual clinical and cultural competencies to their practice. A lack of cultural concordance between patients and health practitioners has been linked to reduced patient satisfaction, access to health services and adherence to treatment regimens (Lee et al., 2020). It is therefore important for whānau (extended family) to be able to choose if they want to receive treatment from Māori practitioner(s). However, Māori have long been under‐represented across health professions in Aotearoa (Waitangi Tribunal, 2019). Ratima et al. (2007) identified the drivers of these inequities as being political, demographic, cultural, historical, financial and academic factors.

There are striking parallels across both the health and tertiary education sectors. Research by McAllister et al. (2019) has confirmed Māori academics make up approximately 5% of the total academic workforce and the efficacy of universities' diversity and equity programmes and their commitment to Te Tiriti has been questioned. For example, Barton and Wilson's (2021) recent study of the experiences of Māori nurse educators found limited support for educators transitioning into nursing education, unrealistic workloads and systemic racism within nursing programmes. They recommended instigating a monitored and planned approach to achieving equity, cultural supervision for Māori staff and zero‐tolerance policy for racism.

Alongside these concerns, research affirms that incorporating Indigenous perspectives and values is beneficial in recruiting and retaining students in tertiary education, alongside active mentoring, community involvement, role modelling and an institutional commitment to Indigenous success (Curtis et al., 2012). Conversely, Cormack et al. (2018) identified that Indigenous students can struggle with navigating expectations around Western medical and academic practices alongside traditional cultural values and ways of being.

Māori students' experiences of racial discrimination are currently being researched by Te Mana Ākonga, the National Māori Tertiary Students Association. The Tertiary Education Strategy (Ministry of Education, 2020) requires New Zealand tertiary education providers to meaningfully incorporate te reo me ōna tikanga (Māori language and protocols) and uphold te Tiriti responsibilities within everyday teaching practice. There is also a requirement to reduce barriers to Māori student success and create safe inclusive places of learning that are free from racism. These requirements are amplified in Ka Hikitia (Ministry of Education, 2013), the Māori Education Strategy. This outlines the requirement of the tertiary education sector to provide facilitation and brokerage support for Māori learners and their whānau, in ways that work for them, to ensure their voices are heard and responded to appropriately. Despite this aspirational policy, educational inequities remain systemic (Statistics New Zealand, 2020).

Māori make up 6% of the occupational therapy workforce and are underrepresented in proportion to their 16% demographic within the overall population (Occupational Therapy Board of New Zealand, 2021; Statistics New Zealand, 2021). This is not sufficient levels to ensure that Māori whānau have a real choice of health services and/or practitioners (Te Rau Matatini, 2009). Ideally, Māori whānau should be able to have an occupational therapist who is clinically, politically and culturally competent. Whānau should be able to expect to receive healthcare that engages, cares for and treats them in a way that fits with their culture.

Due to the legacies of colonisation, Māori disproportionately carry the burden of disease and injury. Twenty‐five per cent of Māori live with a disability (Statistics New Zealand, 2015) and are therefore likely to need the support of an occupational therapist. This deepens the polemic of the scarcity of Māori occupational therapists.

More Māori occupational therapy students need to be recruited, graduate and remain within the professional field. Issues around the retention of Māori occupational therapy students have been a longstanding unresolved issue for the sector (Gray & McPherson, 2005; Jungersen, 1992; Te Rau Matatini, 2009). Part of a wider study on the experiences of Māori occupational therapy graduates; this paper addresses a specific gap in the literature about Māori graduates' recollections of the institutional barriers to studying occupational therapy.

METHOD

Kaupapa Māori theory (Smith, 2012) informs and shapes this study. Kaupapa Māori philosophy comes from mātauranga Māori, the knowledge and experience of being Māori and is strongly influenced by critical theory (Pihama, 2010). It centres Māori tikanga—cultural values, customs and protocols—that ensures that the research process is culturally safe. Kaupapa Māori research is consciously designed to contribute to advancing Māori aspirations and amplifying Māori experiences (Moewaka‐Barnes, 2000).

Ethical approval was obtained through Auckland University of Technology Ethics Committee, and the study was strongly informed by the Māori ethical framework Te Ara Tika (Hudson et al., 2010). A critical Māori Advisory Whānau was also utilised to ensure the study had cultural, political and spiritual tautoko (support). Most participants in this study chose to be identified, along with named people in quotes.

In this qualitative study, seven Māori occupational therapy graduates were interviewed in March–May 2018 about their experiences choosing and then studying occupational therapy (Davis, 2020). The first seven volunteers were a convenient representative sample of the workforce. Data saturation was achieved. The pūrākau were recorded, transcribed and then reviewed for accuracy by participants. This paper presents their pūrākau specifically related to their experiences of institutional barriers. In keeping with Māori tikanga, all participants received a small koha (gift) in recognition of their contribution to the study.

The Māori occupational therapy graduates were recruited using purposeful sampling. An offer to be part of the study was advertised through the Occupational Therapy Board of New Zealand. The inclusion criteria were that they self‐identify as Māori, are an occupational therapist and had completed their studies in New Zealand. The first seven who volunteered represented the demographic of registered occupational therapists thereby completed recruitment.

Whanaungatanga (active relationship building) is imperative to establish connections within the pūrākau process (Lee, 2008; Wirihana, 2012). The sharing of pūrākau occurred kanohi ki te kanohi which helps build trust and allows participants to retain some control (Bishop, 1996). Pūrākau are shared via the prompts of semi‐structured interviewing, with open‐ended questions. It is critical that pūrākau come from the participants' own experience (Hall, 2015); thus, care was taken so participants had time to talk about what was important to them.

The Pū‐Rā‐Ka‐Ū analysis framework (see Table 1) used in this study was adapted from the work of Wirihana (2012). Members of the Critical Māori Advisory Whānau provided cultural and political advice about the meanings of each component of the word to ensure it fits with the study and also with the lead author's own whānau, hapū and iwi (tribe). Using this analysis method helped with uncovering the layers of meanings from the stories (Lee, 2005) and ensured that they analysis came from a Te Ao Māori (Māori worldview). These layers were then sorted into themes. The interpretation of the pūrākau came from an inductive analysis.

TABLE 1

Pūrākau analysis framework

Element of Pūrākau	Interpretation
Pū source of desire to be an occupational therapist	Whakapapa (genealogy) being a member of a whole Wairua (Spirit) growth, your gift starts to show Dream A dream that matures into reality Seek knowledge the focus, beginning of growth
Rā inspirational experiences that provided enlightenment	Māramatanga wisdom, mātauranga, growth and development, mature Wairua meaning to everything, show the path, guiding
Ka past experiences that impacted future aspirations	Moemoeā (dreams) plans for the future, higher meanings Pakari learnings from the past, mature, gives meaning to the present, teaching others
Ū the source of sustenance	Mātauranga teachings, lessons, if retained then are stronger Kaumātua from elders, truths about life, help navigate

Source: Adapted from Wirihana (2012).

The four concepts of this analysis framework were used to make sense of the themes that emerged from the stories. Pū looked at the source of desire to be an occupational thearpist. Rā looked at inspirational experiences that provided enlightenment. Ka looked at past experiences that impacted future aspirations. Ū looked at the source of sustenanace. The use of the Critical Advisory Whānau ensured that this analysis framework had rigour and was also checked with author of the original work. This type of careful checking fits with kaupapa Māori as Wirihana (2012) highlighted that it is important to have multiple feedback systems to ensure the research is tika and Hudson et al. (2010) reiterates how important it is to have robust discussions with Māori when dealing with ethics.

Research standpoint (Harding, 1993) is important as it reveals something of who is holding the pen and something of how the authors position themselves in the world. The first author is a Māori occupational therapist with whakapapa (genealogical) links to Ngāpuhi, Ngāi Tai and Ngāti Porou. The second author is a Pākehā (white settler) activist scholar with a background in public health who is committed to the pursuit of racial justice.

A limitation of the study is that it captures experiences of Māori OT graduates over a 20‐year period without the nuance of being able to track differences over time. Future studies might want to factor this into their study design,

FINDINGS

The Occupational Therapy Board of New Zealand provided statistics of the demographic of the registered Māori occupational therapists. It was calculated in a way to ensure that those who were in this study represented the population (see Table 2).

TABLE 2

Māori occupational therapists for representative sample (insert here)

Demographic factor	Number of Māori occupational therapists (T = 7)
Studied at Auckland University of Technology	5
Studied at Otago polytechnic	2
Male	1
Female	6
0–4 year experience as an OT	2
5–9 year experience as an OT	2
10–14 year experience as an OT	1
15–19 year experience as an OT	1
20–24 year experience as an OT	1

Institutional barriers were one of the connecting themes across the overall pūrākau analysis. This was able to help answer the research question, ‘What are the experiences of Māori selecting and completing an occupational therapy qualification in New Zealand?’ Identified institutional barriers included (1) cultural dissonance in curriculum, learning styles and assessments, (2) cultural (in)competency and (3) the limitations of (Western) pastoral care. Interestingly enough, these were common themes for the seven participants that ranged over the two‐decade time frame when they did their study.

Cultural dissonance

Historically, colonial education has been used as a mechanism to enable colonisation and compulsory assimilation of Indigenous peoples (Simon & Smith, 2001). Māori often describe the education system as mono‐cultural —privileging the viewpoints of Pākehā (Pitama et al., 2018).

Cultural dissonance is a sense of disharmony or conflict usually experienced in the midst of an unfamiliar environment. It can occur while travelling, migrating or in the context of a classroom. Several participants reported dissonance or separation between what they knew as Māori and what academic staff taught them regarding te Ao Māori (the Māori world).

Shaz recounted,

The more I learnt, the more I realised, that we were being taught … were Western constructs and, using words that really did not jive with a Māori way of being … I was pretty aware that I wanted to work with Māori. And yet none of the models that we were being introduced to would fit with our whānau.

Learners have diverse learning styles and research by Olivier et al. (2021) has identified that occupational therapy students prefer collaborative and participatory approaches. O'Toole (2014), in a review of teaching practices in Aotearoa, Canada, United States and Australia, found the expert‐novice model widely in use within the Western tertiary education sector had limited alignment with Indigenous learning preferences. Riwai shared,

… it's very Pākehā learning. And the programme, while it can be applied in a cultural setting and by Māori practitioners, it's learning things from another worldview and that's always going to be challenging … sort of takes me a while to take things in and I can easily miss what's being taught you know, particularly if it's … from a different paradigm … Not because I'm not bright but … being Māori I think we learn differently, and we think differently. But at the time I thought I was dumb.

Pūrākau identified a range of challenges surrounding assessments. The majority of assessments were in a written format. Some participants felt this did not accommodate diverse learning styles. Aniwa noted it would be beneficial to be ‘given the option to do your exams and assignments verbally’.

Participants highlighted specific apprehensions about how cultural components were assessed and the competency of the assessors. Linda shared,

So just about every assessment you'd have to do some sort of cultural consideration, biculturally …, some people get full marks and they cannot even pronounce the name right and I'm thinking ‘that's supposed to be around cultural sensitivity’ … [If] the tutors were Māori then they'd know.

Cultural (in)competency

Kawa whakaruruhau or cultural safety was developed in Aotearoa by Irihapeti Ramsden (2002). It was in response to recruitment and retention issues of Māori nurses, institutional racism and breaches of Te Tiriti. Cultural safety guidelines have been in effect across the health sector since the early 1990s. Jungersen (1992, p. 746) explained,

As long as Māori people perceive the health service as alien and not meeting their needs in treatment, service or attitude, it is seen as culturally unsafe.

There are specific cultural safety expectations of being a registered occupational therapist (Occupational Therapy Board of New Zealand, 2015, p. 2). The bicultural competency states,

You treat people of all cultures appropriately. You acknowledge and respond to the history, cultures and social structures influencing health and occupation in Aotearoa New Zealand. You take into account Te Tiriti o Waitangi the Treaty of Waitangi and work towards equal outcomes for all your clients.

At one of the occupational therapy departments, the students could elect to opt‐in to Māori health. This sent a problematic message to students about the lack of importance of Māori health in occupational therapy curriculum. Liana stated,

Everyone should do those Māori papers …. Bearing in mind that we are a multicultural society but there's a lot of Māori people that need the most help usually, you should understand this person better that's at the centre of our practice.

Riwai reported having to navigate a series of culturally unsafe situations while studying.

My supervisor took me in to see a client and … this is kuia [female elder] who would only kōrero [speak] Māori, so she took me in there and said ‘Oh this is Riwai, he's Māori’ expecting me to communicate with this kuia. And because I'm not fluent and I'm also not from that area and that was really embarrassing for me. … I do not think she really knew what she was doing, she just thought ‘oh well let us just put these brown people together and make them talk to each other because that's what they do’.

This shows how assumptions and the lack of clear communication from the supervisor put the student into a culturally unsafe position. The supposedly good intentions from the supervisor can now be seen as an act that cause unnecessary tension for the student and potentially the patient.

On another occasion, he noted,

Just seeing things … that were quite uncomfortable for me in terms of Māori patients … might be having incontinence issues … or you know may have been hoisted and not properly covered just things that really, affected me … I would talk to the supervisor and say ‘should we have put something on her?’ and she's like ‘no when people come into the hospital they are a patient and there's it’ … and, I just remember feeling really confused like, ‘no way!’. We can treat our people with dignity no matter where they are.

These pūrākau reinforce the need for teachers to strengthen their cultural practice. Tertiary Education policy (Ministry of Education, 2013; Ministry of Education & Ministry of Business, 2014) further articulates these requirements. Both Bishop (1996) and Walker (1990) have articulately argued that under Te Tiriti, non‐Māori have a responsibility to address the unmet health and educational needs of Māori. Furthermore, this collaboration and allyship are critical as Māori are currently a minority population within their own country.

Limitations of (Western) pastoral care

A culturally safe learning environment is one that is conducive for Māori and provides a place that Māori want to be, because it fits with what makes sense from a Māori worldview. Māori students need to be able to seek and receive appropriate pastoral care. Whanaungatanga, the active process of relationship building, is critical from a Māori worldview for fostering connections between people (Bishop, 1996). Aniwa emphasised the value of genuine and long‐standing relationships:

… you put me in a room of Māori mentors, peer supervision or whatever, I do not even know them, I'd need to have the time to get to know them before I go cry on their shoulder.

Māori administrators, liaison officers and a placement coordinator were all positively embraced by participants. The main support they provided was to pro‐actively ‘check‐in’ with Māori students to see if they needed help. Not unexpectedly, there was universal support for the recruitment of more Māori lecturers and placement supervisors echoing the research of McAllister et al. (2019). Shaz shared,

Kristi Carpenter was here at Otago and, and I when I started to ask to have a kaupapa Māori placement, she particularly went out of her way to try and find one because there were not really any on offer.

Participants had extensive pūrākau around feeling disconnection within occupational therapy departments and with Tauiwi academic staff. These experiences ranged from feeling unsupported through to occasions, as illustrated above, where cultural safety was not maintained.

Leana wanted academic and allied staff to proactively create opportunities to build connection by allocating dedicated time for whanaungatanga and sharing kai (food).

Building that peer support network … maybe having a space you know once a week say for instance where you came together, like a lunch together or you know something to kind of vent about stuff … time to have that conversation … in a safe space … I think [it] would be beneficial because then you have got people you can lean on and just maybe having like a lecturer come in and actually see that perspective of the Māori students because you often see them not often engaging and or not coming to lectures or things because they, because they are boring like, having some sort of stimulation you know, to get them there.

The majority of participants volunteered that they had a significant personal issue(s) while completing their study. These ranged from the passing of a loved one, ending a long‐term intimate relationship to resurfacing past trauma. This led to some having to re‐sit a paper, dropping out of the programme and/or having to take time out to work on themselves. There were concerns about the costs and complexities of having to wait a whole year to re‐sit a paper and the practical difficulty interpreting questions for assignments. Ngaire talked about how it was hard to get appropriate pastoral and academic support.

I was lining up with these other students to talk to and she was like ‘oh sorry Ngaire [I] do not have time’ … I tried it three times … I failed that paper … it was really difficult, you had to email your lecturers and … if you were like me, did not have a computer at home, and then you go to the computer lab and all the computers are being used, I'm like ‘oh for god's sakes hang on …. I'll send you smoke signals’

Aniwa felt apprehension about asking for the help. She commented,

… feeling out of their depth and needing help. You know just going back to the real basics … And I know why we do not do it in school: it's resources and money and I get that. But if we are trying to retain all students. And also, you know this focus of ours is Māori students then that's where you have got to start … A lot more mental health strategies, a lot more emotional health strategies to, to be able to look after yourself.

If Western tertiary education providers are failing Māori (Taonui, 2009), maybe it is time to paradigm shift. Participants raised the idea of having a dedicated Māori cohort of students or locating an occupational therapy programme within a Māori whare wānanga (university). Ngaire explores,

If we were able to learn alongside the carvers … there'd be a lot more collaboration and then the Māori students that go there would, know more about OT. I think we do need to collaborate with our wānanga throughout the country … Because they are capturing a lot of Māori, but they do not have an avenue for OT.

Amongst participants, there was a strong sense of wanting to ensure that the current and future students are given a fair chance, by receiving appropriate support, reducing barriers and developing their cultural identity as Māori. Informal whānau and cultural support was widely utilised by students.

DISCUSSION

This paper partially answers the research question ‘What are the experiences of Māori selecting and completing an occupational therapy qualification in New Zealand?’ It examines institutional barriers to Māori occupational therapists navigating their tertiary qualifications, from the critical perspective that institutional racism, despite the best efforts of some, has become normalised within occupational training in Aotearoa. The institutional barriers of cultural dissonance, cultural (in)competency and the limitations of (Western) pastoral care to Māori student success were described previously.

Cultural dissonance is where there was a sense of disconnection of what the participant knew as ‘being Māori’ and the culture of the institution. The culture of the teaching approaches and assessments, including assessments of cultural competency, did not seem to fit with the participants' own culture, values and worldview. This is consistent with Cormack et al.'s (2018) study of Indigenous medical students.

Cultural (in)competence was shown through the structure of systems and through the educator. Putting students into culturally unsafe situations is unacceptable and shows the need for educators themselves to be culturally competent. This incompetence also highlights the institutional barriers that deny all students having an opportunity to learn specifically about Māori health. It also showed the limitations of (Western) pastoral care highlighted the struggles that the participants went through. Providing pastoral care needs to be built from a foundation of relationships and trust built over time.

Racism has allowed these institutional barriers to flourish unchecked. In the context of Aotearoa, racism against Māori is often a legacy of settler colonisation. It is a power system that privileges Pākehā and disadvantages Māori. Institutional racism manifests as monocultural policy and practice: sometimes as a deliberate action and other times as inaction in the face of need (Came, 2014). Berghan (cited in STIR & NZ Public Health Association, 2021, p. 9) describes it as ‘a denial of freedom that undermines our potential to flourish’.

The current ‘mainstream’ tertiary education sector is strongly influenced by Western epistemology and teaching practices (Jeffery, 2005). For many Pākeha, these monocultural practices are seen as ‘normal’ and as a result of the legacy of colonisation. Te Ao Māori is therefore wrongly considered exotic and other (Came et al., 2019). The detection of monoculturalism and/or institutional racism requires critical thinking, empathy and what Freire (2000) described as conscientisation.

We need the entire tertiary education system—‘mainstream’ and Māori—to provide culturally safe educators, culturally safe classrooms and inclusive bicultural curricula. This will allow Māori students to ‘be Māori’ while on campus, on placements and ultimately in the health sector. This is critical if we are to produce graduates who can work effectively with whānau to address inequitable social and health outcomes: a key government priority and driver of the current health sector reforms (Ministry of Health, 2020).

Institutional racism within the tertiary sector is a wicked problem. Given the geographic specificity of racism (Dunn & Geeraert, 2003), in the context of Aotearoa upholding Te Tiriti o Waitangi needs to be foundational to anti‐racism praxis. Anti‐racism has been defined locally as Institutional racism will not spontaneously resolve. Rather, evidence suggests, given the entrenched power dynamics, a planned systems‐based approach holds the most promise for sustained transformation (Came & Griffith, 2017). We respectfully suggest that the tertiary education sector in Aotearoa needs to urgently develop, implement and then evaluate a robust anti‐racism action plan co‐designed with Māori. Consequently, individual tertiary education providers need to co‐design plans that then inform the work of health faculties and occupational therapy departments.

… the art and science of naming, reducing, disrupting, preventing, dismantling and eliminating racism. It takes a multiplicity of forms but centres around solidarity with those targeted by racism, an analysis of power and a commitment to reflective, transformative practice. (STIR & NZ Public Health Association, 2021, p. 9)

Anti‐racism action plans need to address issues such as decolonising white Western curricula to make sure mātauranga is threaded through the curriculum. We need Māori teachers in front of students and designing assessments. We need Māori academics on reading lists and connections with Māori professional networks in the profession. All teachers need to be proficient in bicultural practice, Te Tiriti and anti‐racism, with base level understanding of te Reo me ōna tikanga (Māori language and protocols). Pastoral care needs to be infused with manaakitanga (taking care of), kaitiakitanga (guardianship) and aroha so Māori students are proactively supported as they navigate the university. Some examples of how universities can proactively support Māori is by providing more whānau room tuakana‐teina (older‐younger sibling) programmes, more Matariki (Māori New Year) and Māori graduation celebrations. Universities can build environments on campuses needs that make visible mana whenua with native plantings, and maybe there could be hangi (traditional Māori cooking method) on campus.

Going deeper dealing with racism within the tertiary education section means changing more than curricula and incompetent educators. For transformation to occur, te upoko (the head, intellect), te ngākau (the heart and feelings) and ngā ringa (the hands) must be engaged (Came et al., 2019). One suggestion is the development of health promoting universities that routinely engage with students and staff about their wellbeing and then co‐design tailored programmes to address identified needs (Came & Tudor, 2018). Addressing racism is about love, accountability, monitoring, power‐sharing and re‐imaging a bicultural future where universities would be Te Tiriti based.

If ‘mainstream’ tertiary education institutions cannot provide culturally safe learning environments, perhaps it is timely for the development of a kaupapa Māori occupational therapy programmes based in whare wānanga. It was shown in the findings that there is a need to incorporate Māori world views and values, have models that will work with Māori whānau, provide teaching and assessment that work for Māori, learn about Māori health, provide culturally safe learning environments, prioritise whanaungatanga and have Māori staff.

Within Aotearoa, there are three whare wānanga who provide qualifications from certificate to doctorate levels, namely, Te Wānanga o Aotearoa, Te Wānanga o Raukawa and Te Whare Wānanga o Awanuiārangi. Teachers and educators are grounded in kaupapa Māori and so are able to deliver programmes in a culturally enriched way. A kaupapa Māori occupational therapy qualification could produce graduates with both clinical and cultural expertise, setting a new standard for the profession. This could be the place where Māori will be culturally safe when studying occupational therapy.

This study also identified that further study is required into understanding Māori experiences of occupational therapy education programmes. We need to know more about both what is working and what is not working to instigate the necessary transformative change to enable Māori students to flourish. We wondered if an annual nationwide Māori student programme satisfaction survey could be implemented and/or an annual Māori student feedback wānanga could be held—led by Māori staff and alumni to get direct input into strengthening occupational therapy training. Clearly, existing ‘mainstream’ student feedback mechanisms are not capturing or responsive to Māori perspectives.

This study addresses a gap in the literature; however, its small sample size limits its generalisability. It is useful to note that some of the study's participants trained some decades ago, but the analysis presented here broadly covers graduates over the entire last 25 years. The focus of the analysis is a fulsome picture of a diverse cohort of graduates, but it does not capture changes over time. Further research would be useful with recent Māori graduates to see how experiences are changing overtime. Likewise, research on why some Māori occupational therapy students do not complete their studies would provide insights, as would research on Māori staff experiences of teaching occupational therapy. This type of research will help with identifying ways to improve Māori students/graduates experience of occupational therapy training.

CONCLUSION

Occupational therapy departments are not separate entities from the Western institutions in which they are embedded. More resources—such as time, energy and money—need to be invested to analyse, critique and transform Western curriculum, teaching strategies, environment and support systems so that Māori students can flourish. A planned, systems change approach is needed to systematically address institutional racism.

This research was completed to support the recruitment and retention of Māori occupational therapists. By providing safe learning environments for Māori students, we are likely to see more Māori graduates who will ultimately provide families and whānau the option to choose both culturally and clinically competent occupational therapists.

FUNDING INFORMATION

Funding was received from Ngā Pou Mana Kete Aronui Scholarship, Te Rau Ora Māori Health Leadership Scholarship, Counties Manukau District Health Board Mātātupu Fund and the Māori Education Trust.

CONFLICT OF INTEREST

The authors have no conflict of interest to declare.

AUTHOR CONTRIBUTIONS

Georgina Davis developed the study concept and design, collected the data and did the analysis and interpretation. Heather Came was the supervisor of the study. Georgina Davis and Heather Came drafted and finalised the manuscript.