Māori nurse practitioners: The intersection of patient safety and culturally safe care from an Indigenous lens

Abstract

Background

Dynamic and complex health systems require innovative and adaptive solutions to support patient safety and achieve equitable health outcomes for Indigenous populations. Understanding the ways by which Indigenous (and specifically Māori) nurse practitioners (NPs) practice patient safety is key to enhancing Indigenous health outcomes in predominantly westernized healthcare systems.

Aim

To describe Māori NPs perspectives on patient safety when caring for Māori and understand how Māori NPs deliver safe health care.

Methodology

A group of five Māori NPs worked alongside a Māori nurse researcher to explore their perceptions of patient safety. Together, they held an online hui (focus group) in early 2024. Data were analysed collectively, informed by kaupapa Māori principles, using reflexive thematic analysis.

Results

Māori NP experiences, expressions and understandings of patient safety envelop cultural safety and have many facets that are specific to the needs of Māori populations. The three themes showed: (1) Te hanga a te mahi: the intersection of cultural and clinical expertise; (2) Mātauranga tuku iho: the knowledge from within, where safe practice was strongly informed by traditional knowledge and cultural practice; (3) Te Ao hurihuri: walking in two worlds, where Māori NPs navigated the westernized health system's policies and practices while acting autonomously to advocate for and deliver culturally safe care.

Conclusion

The Māori NP lens on patient safety is vital for promoting culturally responsive and effective health care. By recognizing the unique needs of Māori patients and families and incorporating cultural perspectives into practice, Māori NPs contribute to a more comprehensive and inclusive approach to patient safety that goes beyond westernized principles and practices.

Patient or Public Contribution

No patient or public contribution.

Implications for the profession and/or patient care

• What problem did the study address: This research illuminates the perspective of Indigenous Māori Nurse Practitioners (NPs) on patient safety. Patient safety is generally interpreted within the context of standardization of nursing care on the premise that errors and risk will be minimized. However, this construct can result in othering and diminishing of cultural knowledge, particularly in colonized countries who are confined by dominant westernized practices and systems. This study sought to understand the interpretation of patient safety by Māori NPs and how this translated into their clinical practice.

• What were the main findings: Māori NPs offer a different perspective that naturally integrates patient safety and culturally safe practices into their clinical routines and interactions. Navigating within diverse knowledge systems, they have developed an advanced praxis that answers to the demands of whānau (families), employers, and regulatory authorities. When their employing organizations implement strong cultural principles, NPs are better supported in fostering culturally safe relationships with whānau.

• Where and on whom will the research have an impact: This research impacts Indigenous people, particularly Māori, clinicians, and employers interested in fostering clinically safe workforces and environments to improve equity of health outcomes. This research is equally relevant for workforce development and agencies that regulate clinical practice. The research provides visibility of the hybridity between clinical and Indigenous knowledge of Māori NPs in clinical practice and the importance of developing own‐grown Indigenous clinical workforces. We recommend including Māori NPs at a policy and governance level to ensure patient safety measures are culturally informed.

Reporting method

This qualitative research adhered to the Consolidated criteria for strengthening the reporting of health research involving Indigenous peoples: the CONSIDER statement (Supplementary file 2) and the Consolidated Criteria for Reporting Qualitative Research (COREQ) guidelines (Supplementary file 1).

What does this paper contribute to the wider global clinical community?

• Globally, evidence is lacking of the significance of the integration of culturally safe practice as a mechanism of patient safety and positive patient outcomes.

• Māori NPs have honed the ability to effortlessly integrate clinical practice into their everyday cultural values, while implicitly understanding the importance of Indigenous culture to ongoing relationships and optimal health outcomes.

A patient safety approach that derives from Indigenous knowledge could realize greater benefits. The contributions that Indigenous knowledge provides within standardized, complex westernized healthcare systems, are unlikely to identify sophisticated and flexible solutions required to achieved Indigenous health equity.

1. INTRODUCTION

Patient safety is fundamental to the provision of health care in all settings. However, avoidable adverse events, errors and risks associated with health care remain major challenges for patient safety globally (World Health Organization [WHO], 2023). The WHO (2023) defines patient safety as ‘a framework of organized activities that creates cultures, processes, procedures, behaviours, technologies, and environments in healthcare that consistently and sustainably lower risks, reduce the occurrence of avoidable harm, make error less likely and reduce its impact when it does occur’ (para. 2). Coordinated global efforts to enhance patient safety and standardization across nations have been a priority for countries that have adopted dominant westernized healthcare systems, including Aotearoa, New Zealand. With an ageing global population and a rising prevalence of life‐limiting physical and mental illnesses, especially among Indigenous populations in colonized countries, ensuring patient safety requires adaptive rather than standardized approaches (Curtis et al., 2019; Pelzang et al., 2017; Wispelwey et al., 2023). As health care evolves and the demand for quality patient care remains unmet, standardization proves inefficient and counterproductive (Pedersen, 2016) for achieving equitable health outcomes within such a complex system.

The significance of patient safety has been emphasized for nursing in response to the evolving nature of healthcare practices and the increasing complexity of medical interventions (Cathro, 2016). In 2019, the COVID‐19 global pandemic reinforced the heightened risks faced by racially minoritised people and the work of Indigenous nurses to safeguard such communities (Clark et al., 2021; Davis et al., 2021). Amid the pandemic and a healthcare system that systemically underserved Māori (the Indigenous people of Aotearoa New Zealand), Māori communities, including Māori nurses, swiftly mobilized to provide appropriate comprehensive COVID‐19 responses before government action (Russell et al., 2023). Their leadership demonstrated the effective outcomes achievable for all in Aotearoa, particularly when Indigenous nurses exercised their autonomy and took charge (Davis et al., 2021). Therefore, healthcare delivery during this time highlighted significant implications for patient safety, intensifying the drive to change safety measures across all facets of care (Clark et al., 2021).

Patient safety as it currently stands in Aotearoa New Zealand, has not served Māori as evidenced by ongoing health inequity, poor patient experience and adverse events (Graham & Masters‐Awatere, 2020; Waitangi Tribunal, 2023). Further, Indigenous nurses are underrepresented in the workforce and themselves face systemic and personal racism (Brockie et al., 2023; Wiapo et al., 2024). Yet international research highlights an Indigenous workforce is key to enhancing Indigenous health outcomes (Brockie et al., 2023; Komene, Gerrard, et al., 2023). Investigating Māori NPs perspectives of patient safety gives the opportunity to centre Indigenous worldviews that support culturally safe practice.

2. BACKGROUND

Patient safety in Aotearoa (NZ) is governed under various legislative acts. The Code of Health and Disability Services Consumers' Rights (1996) establishes the rights of patients, including their right to appropriate standards of care, effective communication and services that are responsive to cultural requirements and ‘the needs, values and beliefs of Māori’ (Right 1, (3)). Providers are expected to comply with the Code, regulated under the Health and Disability Commissioner Act (1994). The Health Practitioners Competence Assurance Act (2003) provides mechanisms, through professional regulatory bodies, to protect the health and safety of the public. The Nursing Council of New Zealand (NCNZ) regulate all three scopes of nursing practice (enrolled nurses, registered nurses and NPs), and their function includes setting education and practice standards, registration processes and ensuring registered practitioners are competent and fit to practise (NCNZ, 2012). The Health Quality & Safety Commission, regulated under the Pae Ora Healthy Futures Act (2022), is responsible for monitoring and improving the quality and safety of health services. This includes improving health and equity, together with the requirement to engage with consumers and whānau (families) to ensure their perspectives are reflected in the design, delivery, and evaluation of health services (Health Quality & Safety Commission, 2023).

Te Tiriti o Waitangi, is the foundational document of Aotearoa, signed in 1840, that established a relationship between Māori and the British Crown, following colonization by predominantly European settlers (Came et al., 2021). Te Tiriti o Waitangi requires the achievement of Māori health equity which is anchored in legislation policy, and strategies governing healthcare services and professional practice (Waitangi Tribunal, 2023). Despite the legislation and apparent commitment to equity, whānau Māori continue to experience discriminatory practices, reducing their access to high quality health care (Cram et al., 2019; Curtis et al., 2019). Racism, poor communication, hostile health environments and rurality result in late and more complex presentations, reduced referrals for specialist interventions and ultimately increased morbidity and mortality rates (Graham & Masters‐Awatere, 2020; Health & Disability System Review, 2020; Tane et al., 2024). Historical and ongoing impacts of colonization within healthcare have meant Māori continue to experience persistent health inequities.

For nurses, cultural safety is a requirement of safe nursing practice in Aotearoa and demonstration of competence (NCNZ, 2012, n.d.). Irihapeti Ramsden (1990) was considered the pioneer of culturally safe practice, which was originally adapted from Kawa Whakaruruhau, a framework for Māori nurses caring for Māori communities. However, despite requirements to deliver culturally safe education and practice since the early 1990s, it is evident that Māori continue to experience unsafe care and experience poorer health outcomes (Waitangi Tribunal, 2023). Cultural knowledge regarding patient safety continues to take a back seat to standardized protocols based on the dominant western lens (Chakanyuka et al., 2022; Curtis et al., 2019).

Since the early 2000s, the NP workforce has increasingly grown reaching nearly 800 NPs in 2024 (NCNZ, 2024). In Aotearoa, NPs are advanced autonomous clinicians with full referral and prescribing authority (NCNZ, n.d.). Systematic reviews of randomized controlled trials provide evidence for the quality of care delivered by NPs and at least equivalent health outcomes to medical doctors (Barnett et al., 2022; Laurant et al., 2018; Martínez‐González et al., 2014). Aotearoa has a population of 5.2 million people, identifying their ethnicities as 17.8% Māori, 67.8% Pākehā (New Zealand European), Asian 17.3%, and Pacific peoples 8.9% (StatsNZ, 2023). Yet the NP workforce is not representative with 9% of all NPs being Māori, while nearly 80% are Pākehā (New Zealand European) (Adams et al., 2022). While workforce disparity poses challenges to providing safe, equitable, and high‐quality health care for Māori (Wilson, Moloney, et al., 2021), there is increasing evidence that identifies the transformative roles of NP toward achieving health equity and social justice (Adams et al., 2024; Carryer & Adams, 2017; Wood, 2020). Given the dearth of evidence on Indigenous NPs globally, our intent is to begin to document the unique contribution of Indigenous NPs.

3. THE STUDY

3.1. Aim(s)

We aimed to describe Māori NPs perspectives on patient safety when caring for Māori and understand how Māori NPs deliver safe health care.

3.2. Research question

As the research sought to explore an understanding of patient safety for Māori NPs the key questions developed by EK and JD were

1. What is patient safety?

2. What does patient safety mean in practice?

3. What supports you in delivering safe care?

4. How do you measure the effectiveness of your practice regarding patient safety?

4. METHODS/METHODOLOGY

4.1. Design

This study is primarily written from the perspectives of five Māori NPs (JD, RD, RO, KT and CD) and one Māori nurse (EK) undertaking doctoral study, collectively referred to as the rōpū (group). The rōpū adopted a shared approach (mahi a rōpū) to guide the direction and content of the study (Wilson, Mikahere‐Hall, et al., 2021). Using a kaupapa Māori methodology and kaupapa kōrero as the research method, the rōpū were positioned as experts in evaluating their understanding of patient safety while facilitating the collection and analysis of meaningful information (Haitana et al., 2020; Smith, 2021; Ware et al., 2018). Kaupapa Māori methodology is considered a decolonizing and Indigenising research tool that does not adhere to set methods but actively engages with Māori worldviews and cultural concepts, including tikanga (cultural practices) and kawa (Māori protocols) (Haitana et al., 2020; Smith et al., 2016; Ware et al., 2018). Kaupapa kōrero, a method that embraces oral knowledge sharing, allowed the rōpū to participate in dialogue (kōrerorero) unpacking dominant narratives regarding patient safety and their understandings in practice (Davis et al., 2021; Ware et al., 2018). Using a culturally informed meeting process (hui) the rōpū participated in whakawhanaungatanga (relationship building) facilitated by karakia (blessings), kanohi kitea (a face that is seen is known) and pepeha (identity through connections of ancestry and landmarks). Such steps are a central component of Māori research, valuing the importance of relationships to wellbeing and the construction of knowledge (Wiapo & Clark, 2022).

4.2. Theoretical framework

Indigenous research methodologies actively decolonize and serve as a critical site for resistance (Mead, 2022; Smith, 2021). They offer legitimate alternatives to westernized knowledge and research paradigms by valuing a rich diversity of ideas that contribute to multiple worldviews, theories and practices (Mead, 2022; Smith, 2021; Smith et al., 2016). A kaupapa Māori approach provides the framework to inform Mātauranga Māori (Māori knowledge) and shed new light on colonized systems and processes by informing cultural and contextual issues that have historically impacted and continue to affect Māori (Smith, 2021).

4.3. Study setting and recruitment

To ensure the rōpū were actively participating throughout the research process, Māori NPs were invited by a Māori NP (JD) and a Māori nurse researcher (EK) at a face‐to‐face national Māori NP meeting to participate as co‐investigators of this research. Four Māori NPs (RD, RO, KT and CD) expressed their interest and willingness to fully participate in the research and be authors of any publications arising from the research. The NPs represented both secondary and primary healthcare settings.

4.4. Data collection

Data was collected using online hui (focus groups). Emphasis was placed on the quality of in‐depth, rich contextual experiences and establishing diversity, rather than universality of knowledge (Palinkas et al., 2013). The term hui, defined as to gather, congregate and assemble, was used in this research to support a sophisticated meeting process of reciprocal knowledge exchange (Lacey et al., 2011). Data were collected using kaupapa kōrero to ensure ongoing dialogue (kōrerorero) was collected in a culturally safe way. In total, three hui approximately 60 min each were conducted and recorded online with discussion points informed by the aims and questions of the research. Recordings were transcribed by authors EK and JD and the rōpū were all asked to review transcripts. Data were collected between February 2024 and concluded in March 2024.

4.5. Data analysis

Braun et al.'s (2018) reflexive thematic analysis aligns with a kaupapa Māori approach, making it suitable for addressing the research question and accurately capturing patterns and themes in the data. This method acknowledges researcher subjectivity as valid and resourceful, positioning the researcher as a storyteller and honouring the voices of socially marginalized groups (Braun et al., 2018). By examining the underlying aspects of dominant patterns of meaning, reflexive thematic analysis complements kaupapa Māori methodology. Although the rōpū was small, it was culturally appropriate and pragmatic for identifying patterns in the data (Moyle, 2016). Data were initially analysed by authors EK and JD through re‐reading of transcripts and engaging in critical discussions, to refine initial codes and themes. Mahi a rōpū (collective data analysis) (Wilson, Mikahere‐Hall, et al., 2021) then occurred via email and the use of a live Word document until consensus was reached. Three final themes were identified which gave an overall picture of Māori NPs perspectives on patient safety.

4.6. Ethical considerations

As the research employed a collaborative approach that invited the rōpū to contribute to the development, conduct and authorship of the research, ethical approval was not required. However, the Te Ara Tika Guidelines for Māori Research Ethics (Hudson et al., 2010) still guided the conduct of this project with consideration given to the concepts of whakapapa (relationships), tika (research design), manaakitanga (cultural and social responsibility) and mana (justice and equity). Collective and individual consent processes were followed to ensure confidentiality was maintained. Data were also stored in a secure cloud server only accessible to the rōpū and researchers EK and JD.

4.7. Rigour and reflexivity

Achieving research rigour in qualitative research involves several key aspects including credibility, transferability, dependability and confirmability (Johnson et al., 2020). The viewpoints and positions of the authors are informed by their cultural and professional backgrounds. All authors of this paper are female, registered nurses or NPs and are dedicated to emphasizing opportunities for transformation and change within healthcare systems. Their commitment lies in the advancement of Māori health equity through Indigenous ways of knowing. The aims, design and theoretical framework of this paper add to the authenticity, reliability and rigour of the research. Culturally informed data collection, analysis and dissemination have ensured Māori aspirations remained at the core of the research process.

5. FINDINGS

The study aimed to explore Māori NPs perspectives on patient safety and to understand how we ensure the delivery of safe health care in practice. Kōrerorero led to the development of three main themes: (1) Te hanga a te mahi: where cultural and clinical expertise intersect, (2) Mātauranga tuku iho: the knowledge from within (3) and Te Ao hurihuri: walking in two worlds. As the sample was small, the quotes used are de‐identified and we use pseudonyms that reflect birds as kaitiaki (guardians or protectors) which aligns with our interpretation of the role of Māori NPs and practice.

5.1. Te hanga a te mahi: Where cultural and clinical expertise intersect

The delivery of truly meaningful health care for whānau Māori meant that for Māori NPs, patient safety was synonymous with cultural safety. Consequently, the experiences of Māori NPs, marked by struggle and transformation, illustrated our hybridity within dominant westernized healthcare systems:

We walk a fine line of clinical obligations and try to make our care fit for our families as best we can but there is a grey area that we walk into. That is the unspoken truth. (Ruru)

Tui went onto describe the relationship between patient safety and cultural safety:

Patient safety and cultural safety come together because how do they [patients] feel about coming and interacting with me? How do they feel? I must create a space where they feel comfortable, which means welcoming their whānau, their mokopuna (grandchildren), to reduce any barriers to access. (Tui)

Ruru elaborated on the spiritual aspect of culturally safe practice and blending this with westernized frameworks to enhance practice, resulting in a more effective approach:

[The] wairua [spiritual] component to our practice, the strong sense of self, having a connection, [understanding that we have strong ancestral connections]…we are not at the beginning our journeys of identity, who we are, where we have come from, we blend this with western frameworks so that we can better justify and mobilise our practice through a blended lens to uplift the way we practice. (Ruru)

Through our discussion, whakawhanaungatanga (making connections) was described as an inherent process and the foundation for developing safe, trusting relationships between Māori NPs and their communities by understanding the people in their care. Whakawhanaungatanga underpinned both patient and cultural safety, and initiated reciprocal relationships, as emphasized by Piwakawaka:

We know that it's going to be a lifetime relationship, so we put in the time; but it's not even putting in the time, because it's just what we do. We understand the value of working with whānau. And maybe, unless it's an acute situation, not even clipping the ticket about anything clinical in that first kōrero [conversation] and contact. (Piwakawaka)

Kuaka elaborated that whakawhanaungatanga is essential as a cultural process that clears the path for progress in any interaction, and as with Piwakawaka, necessary before any clinical concerns can be addressed:

Safety is in the relationship, respectfully and valuing it, whereas for non‐Māori safety is within the clinical transaction. Understanding the expertise that everyone brings into the spaces and not wanting to hold the power, holding spaces for whānau until they feel comfortable to hold the spaces themselves. From there respect, trust, and valuing, then clinical care follows. (Kuaka)

Māori NPs continuously self‐moderated and questioned practice when navigating the intersection of dominant westernized and cultural health paradigms. Ruru's experience highlighted the challenges of applying a westernized approach to patient safety for Māori communities and described how she worked differently, because innately, Ruru is Māori first, and ensured that culturally appropriate processes (tikanga and kawa) are central to her practice:

For the majority of us who are whānau orientated, we will take that step cautiously to ensure that the patient gets the best outcome at the time, and I think that's not spoken about often in terms of how far do we go [to provide care]? And are we outside our scope of practice? How do I make myself safe in this space? (Ruru)

Nurse practitioners readily identified the challenges many whānau Māori had in accessing health care. In Aotearoa, unless under exceptional circumstances, whānau are expected to utilize pharmacies for medication dispensing. For example, Kotuku explained how instead of giving a script for antibiotics, she would give the person all the tablets they needed to complete the course, rather than adding the additional step of needing to go to a pharmacy. Many towns do not have local pharmacy services and rely on overnight delivery to access medications.

Working on the fringes between dominant westernized and cultural health paradigms also negatively impacted the NP's well‐being, confidence and job satisfaction:

We've been trying to do a lot of work with changing people's perspectives on what they think gang culture is and what Māori culture is and trying to navigate both of those worlds at the same time and in our department. And that's been tough. (Kotuku)

Being a Māori NP is challenging, as we often find ourselves as the sole Māori clinician and being loaded with the ‘difficult Māori patients’:

Māori NPs can do this [culturally safe care] without thinking; but an unexpected response is becoming a commodity that everyone wants [cultural loading]—this is the safety net for whānau and where they grow confidence in Māori NPs…because we endure and are accepting of the cultural differences and value the tikanga (traditions) that need to be carried out. (Ruru)

Tui expressed frustration with nursing leadership who failed to acknowledge her value as a Māori NP weaving cultural knowledge into the delivery of services following a natural disaster that had devastating impacts in the region where she worked. Tui's response was eventually celebrated as a safe and successful model for healthcare delivery during times of crisis.

A culturally safe workplace hugely influenced Māori NPs practice. Those that did not understand cultural safety presented challenges as described by Piwakawaka working with a westernized healthcare provider:

One of the [health provider's] philosophies was about having smaller waiting rooms because they don't want people waiting, but that doesn't work when you're talking about whānau, because if there are only five chairs and you bring in your whānau with you, there's not enough space, and we know that Māori families are often big families, numbers‐wise, but also physically.

Tui recounted an experience of being moved to work in a room without explanation, where she felt an overwhelming sense of unease, describing it as the ‘mauri [essence] of a thousand broken souls’. When expressing discomfort, Tui's concerns were dismissed by her nursing directors who said ‘I don't understand it, I will never understand, this is your problem’. This incident marked Tui's first experience of a culturally unsafe environment. Tui's experience showed that cultural safety for Māori NPs is of equal importance to culturally safe care for whānau Māori. Culturally safe environments extend beyond physical spaces and require Māori and non‐Māori allies and leaders prepared to support the work of the Māori NP.

Tui's encounter with overt racism and the appropriation of language by non‐Māori colleagues left her, a fair‐skinned Māori, feeling vulnerable and unsafe, highlighting the importance of allyship and leadership:

I currently work in a job where my two senior managers are not Māori and although they talk about te whare tapa wha and how we should practice in health, I found myself quite early on as an NP sitting in meetings with my senior management team and feeling quite culturally unsafe because I suddenly realised they didn't have a meaningful understanding of Māori models of health and because I look white. I realised they don't get you, and I felt culturally unsafe.

5.2. Mātauranga tuku iho: The knowledge from within

This theme highlighted safe practice informed by traditional knowledge and cultural practices as an extension of being Māori. Māori NPs described a different epistemological tradition, one which frames the way we see the world, the way we organize ourselves within the world, the questions we ask, and the health solutions we seek:

Sometimes I do things and don't understand why I do them, but it's innately Māori within me and we marry the science with the cultural identity of who we are and how we practice. (Kuaka)

This framing is larger than the individuals and the specific moments we work with whānau. Whānau safety encompasses cultural safety and has many facets that are specific to whānau needs as reflected by Kuaka: ‘We treat patients like whanau with respect; dignity and respect is all about understanding where the person is at…. whanau safety and cultural safety is one’. The layers of the kōrerorero show complex intersections between Indigenous rituals and clinical practice:

Patient safety is often defined in a physical sense, but if we put on the person's lens who is entering the healthcare service, then it's quite a different perspective. (Tui)

The cultural difference as described by Piwakawaka:

Our interactions with whānau are about wanting to understand who they are, and how they got where they are… there's quite a differentiation in what our Māori and what our Pākehā whānau would say for them was culturally safe practice.

Kuaka explained observing the practice of another Māori registered nurse colleague; ‘the first thing she did was give him a big cuddle, mihi (acknowledgement) to the wife, took his socks off and started to mirimiri (massage) his feet’:

You just don't get that understanding, that acknowledgment, that commitment, that awhi (embrace). It was just a really special moment, and she still thinks of it as normal, but she didn't realise it was different. Which is never written or spoken about because it's (a cultural ritual) that we do.

Māori NP's understanding and expressions of whānau (family) and patient safety are informed by mātauranga (traditional knowledge) and tikanga (Māori law and lore) as an extension of who we are and where we come from:

My surname means to be the best, be outstanding. During my career as I have carried this name on my badge which is situated on my whare tangata (personhood), I carry the mana (prestige) of that name, and I must uphold it. If we're not here to serve and advocate and be caring, why be in this job? (Tui)

Ruru expanded on how care is a ritual that honours all aspects of life, including death to support whānau Māori effectively:

How do we mitigate [emotional harm during death] in terms of our practice in general? It comes down to how we roll as Māori and the acknowledgment and understanding of the concept of whānau ora and whānau rā [wellbeing in life and death]. In terms of the death certificates and cremation and how we work in its entirety. (Ruru)

Māori NPs are bound by Indigenous standards of practice (tikanga) to ensure the communities are safe and well‐being sustained. Tui described rituals of encounter as a responsive method to both reduce inequity and prevent further harm at each connection point. The reference to ‘our third eye as Māori’ symbolizes a heightened awareness that enables Māori NPs to integrate cultural insights attuned to the needs of whānau Māori:

Using a manuhiri process (rituals of encounter) reduces the physical and emotional harm; to check waiting patients and who needs to be seen asap [acuity], our third eye as Māori catches that. (Tui)

Māori NPs occupy an insider perspective, as we are Māori first and through this lens understand inequity through personal and professional experiences:

Because I was brought up around gang whānau it doesn't bother me that much and I sometimes forget that I don't have those same already preconceived biases that other people do. And I have to remember that myself to understand both perspectives, why our staff feel threatened or unsafe. Because I don't [feel unsafe] that's how I was brought up. (Kotuku)

Tui reflected on the significant difference in practice compared to non‐Māori colleagues which Tui attributes to, ‘That personal connection to it. This runs deeper than a job for me’. Kotuku further highlights the differences in perceptions of culturally safe practice between Māori and non‐Māori:

Most of our staff, unfortunately, are not Māori either and not being able to grow our own quickly enough, has led to a lot more IQNs (Internationally qualified nurses) being introduced, and there's nothing wrong with that. But it just is a different type of culture coming from overseas to Aotearoa for starters, and then working in a place where 80% of our patients are Māori.

All expressed a deep sense of commitment and accountability, feeling a responsibility to tupuna (ancestors) to change the whakapapa (genealogy) trajectory for the well‐being of Māori:

We've all come through a Western training system… and we talk differently, depending on the audience for example if it were my Pākehā practice manager, I'm talking about policies and strategies, evidence, and data. And I pull all of that into my practice to convince those [who don't understand cultural aspects] because I already knew in my mind I was safe. I was culturally safe. My whānau were there backing me. My tupuna were with me, pushing me. (Tui)

Ruru extends on the inherent and inherited levels of responsibility by referring to herself as the puna—a spring from which Indigenous knowledge and knowing about well‐being are passed from one generation to the next.

5.3. Te Ao hurihuri: Walking in two worlds

The final theme explored how Māori NPs navigated a colonized health system from a Māori worldview. Our experiences speak to the complexity of a westernized landscape, complying with legislative and governing requirements while operating within a multitiered health system:

We are working in grey areas and ensuring that you maintain the integrity of the care delivered while managing and mitigating risk and simultaneously ensuring ethical pathways to assist with changes to the nature of care. (Piwakawaka)

Consequently, Māori NPs faced the challenge of reconciling westernized legal and ethical frameworks with advocating for cultural safety, as current standards fell short in ensuring safe care for Māori:

I guess we've got policies galore, and they must keep us safe [in our practice], we have to agree with the national guidelines and competencies, the acts that we all have to adhere to. Code of rights, HPCAA act, following processes and procedures. You also have the law and posters that talk about staff abuse. Then you have your training to ensure you are competent to practice at the advanced level. That's the tauiwi (non‐Māori) framework. (Ruru)

Nurse practitioners highlighted discrepancies between the health system's commitment to cultural safety and its actual practices. Kotuku's expression highlighted frustration at the lack of support for proposed changes and felt her expertise, both clinical and cultural, is not acknowledged:

I'm trying to change stuff in the hospital but there is no support there. There are only words where they talk about it [working differently] but their doing is a completely different issue. I'm not alone [in this thinking] but we practice in silos isolated from each other. It's that control and domination that continues to hold us down. I've trained to become a nurse practitioner. Please treat me with the respect and the authority that I have earned to go and do my job well. (Kotuku)

Tui further asserted that Te Tiriti o Waitangi, founding document between Māori and the Crown although should be prioritized in these frameworks was not:

When I look at protocol, I'll read policies and give feedback. And the first thing that annoys me is if Te Tiriti o Waitangi isn't number one. I will fight to have this as number one and use nursing council documents to back me up. (Tui)

The Māori NPs recognized the power of language, with Tui describing difficulty trying to change terminology working for a mainstream hospital service. Tui said

I try not to use the term patient because that indicates patients waiting patiently for good or bad care. Whereas whaiora is a seeker of health… Just a subtle change, because to change the name changes the meaning and engagement. If you can't get simple changes to happen, how can you get the rest across?

Efforts to standardize patient safety within westernized health systems and regulatory authorities often marginalized Māori NPs who held a different worldview. Attempts to unify diverse practices, cultures and relationships into clear categories tended to turn differences into exclusions:

Our patient outcomes are mimicked by the ministry demands. The fact that we [now] have an obese lady that can walk down to the letter box and walk back again and get out of bed is a huge health outcome that has no significance in our health arena. (Ruru)

However, Māori NPs still provided competent clinical care amidst hierarchical power structures and ongoing inequities, balancing cultural responsibilities and expectations which at times, directly impacted relationships, identities and safety:

As a Māori NP I try always to connect with my Māori patients because I inherently know and understand their struggles. I love supporting my Māori patients with their health journey navigating them through the system as most do not know how to do this and need awhi from someone who can advocate for them and explain medications or processes to them in a way they can understand. (Kuaka)

Kotuku's decisions stemmed from a desire to resist and transform a health system they found politically restrictive and unjust, especially in its treatment of Māori:

I wanted to be an NP to have authority over what I can give people and I wanted to be able to help clinically because I wasn't able to make a change in the management role. It was too political and I'm too honest. So, I do what I can in a way that I'm good at it. So that's where and why I sit there because it's not a fair playing field. There is no justice in the system. (Kotuku)

Nurse practitioners voiced different patient safety measures across all facets of care. As said by Piwakawaka, who described treating everyone with respect and measuring effective care based on engagement where patients ‘voted with their feet’. This was also reiterated by Kotuku who said

People will keep coming back [to the NP] and our relationships are being maintained and so without it being said, I feel like that shows that we're doing the right thing. (Kotuku)

In response to a healthcare system that failed to recognize the value of indigenous knowledge, Kotuku reiterated the challenge of demonstrating the ‘invisible’ contributions of Māori NPs, especially when using questionnaires that overlook cultural aspects of care:

All I know is we must produce the evidence to validate our work. It's a matter of getting it on paper to prove and show the value of our work…the stuff that we need to do to prove it [our work and value] is so hard because when do we get time … using a health‐related quality of life questionnaire doesn't necessarily attend to the culture and safety. (Kotuku)

Other efforts to celebrate different measures of safe patient care were discussed including references to Manuka Henare model of ethics Pa Tai Whakawhanaungatanga (1998), Mason Durie's model Te Whare Tapa Wha (1994), and Te Pae Māhutonga (1999), Rose Pere's model Te Wheke (2003):

Safety is when we work together when the power is shared and there is respect. Although I bring my knowledge and legal boundaries. My most important thing when I enter a relationship is manaakitanga (caring) because I am there to host and make you feel safe and cared for … My goal is always to whakamana and improve that person. Even if I haven't changed the [physical] outcome at the end but they leave uplifted then I know I have achieved whakamana and now I have achieved patient and cultural safety. (Tui)

6. DISCUSSION

This study is the first to describe Māori NPs perspectives on patient safety when caring for Māori and explore how Māori NPs deliver safe healthcare which deviates from westernized patient safety practices. Their experiences revealed the delicate balance they had to navigate between the two worlds of dominant healthcare systems and Māori knowledge systems. Māori NPs clearly described how patient safety is synonymous with cultural safety. In Aotearoa, Ramsden (1990) developed and campaigned for kawa whakaruruhau an Indigenous‐led framework used by Māori and specific to the health care needs of Māori. This was then adapted as cultural safety recognizing the power imbalance between health professionals of all ethnicities and those for whom they care (Ramsden, 1990). The persistent poor interpretation and application of kawa whakaruruhau in practice has resulted in few gains for Māori and Indigenous communities worldwide (Brockie et al., 2023; Cram et al., 2019; Curtis et al., 2019). The nursing regulatory authority, the Nursing Council of New Zealand, is recognizing a shift is required towards kawa whakaruruhau, as evidenced by recent consultation (NCNZ, 2023). Supporting kawa whakaruruhau alone is insufficient without a comprehensive understanding of structural mechanisms that marginalize Māori nurses and perpetuate a suboptimal understanding of culturally safe practice (Wiapo et al., 2024).

Indigenous definitions of patient safety are important as Indigenous people's approach to health and wellbeing, like the current healthcare system, is dynamic, relying on spiritual, physical and environmental balance (Marques et al., 2021; Pelzang et al., 2017). Patient safety requires a workforce that harmoniously balances the clinical and cultural in everyday practice. Recognition of the cultural value and transformative potential of the Indigenous nursing workforce requires Indigenous leadership, allyship, and global effort (Brockie et al., 2023; Fournier et al., 2021; Komene, Gerrard, et al., 2023; Wiapo et al., 2024). Indigenous nurses have substantial cultural and clinical expertise to support quality healthcare delivery and achieve equitable health outcomes (Brockie et al., 2023; Hunter & Cook, 2020; Komene, Gerrard, et al., 2023; Wilson, Moloney, et al., 2021). Efforts to embrace Indigenous understandings of patient safety practices, we suggest, foster a more effective response to current definitions of patient safety (Chakanyuka et al., 2022; Pedersen, 2016; Pelzang et al., 2017).

Nurse practitioners working at the intersection of nursing and biomedicine, and within a paradigm of social justice, provide the opportunity for transformative healthcare (Adams et al., 2024; Chulach & Gagnon, 2016; Wood, 2020). Indigenous NPs bring further opportunities from this hybrid space of NP practice through their experiences at the intersections of culture and race. The findings from this study showed how Māori NPs navigated sites of tension and integrated mātauranga tuku iho (personal and cultural knowledge) with contemporary health care. However, those NPs also need an environment that is culturally safe, which in turn supports their delivery of care (Hunter & Cook, 2020). The NPs characterized culturally safe environments that are inclusive of physical structures, collegial relationships and wairuatanga (spiritual safety). Holistic frameworks that reflect Indigenous worldviews (Durie, 1994, 1999; Pere, 2003; Ramsden, 1990) are essential to create and sustain patient, cultural, and health practitioner safety.

Healthcare reforms in westernized health systems have prioritized patient safety through managerialist principles and practices (Stjernholm, 2017). Efficiency and effectiveness, including patient safety, have been driven through sets of standardized indicators and measures (Pedersen, 2016). However, through these processes, the experience and knowledge of nurses (and other clinicians) are devalued and rendered invisible and, paradoxically, may adversely affect patient safety (Heldal et al., 2019). Māori NPs in this study described how they felt at odds with the measurement and safety indicators, which failed to capture the value of their work and their imperative to provide culturally safe care. The Māori NPs spoke of whakawhanaungatanga (ongoing relationships) with whānau as a measurement of safe Indigenous practice. These findings highlight a need to adapt safety parameters to better reflect the individual wellbeing and cultural context. Integrating Indigenous knowledge into patient safety approaches would yield greater benefits, as it offers sophisticated solutions that standardized and westernized healthcare systems may overlook.

6.1. Strengths and limitations of the work

This paper has sought to uplift Māori NP ways of knowing, seeing and doing regarding safe practice, allowing an appreciation of an Indigenous worldview from a kaupapa Māori research space. The contributions of Māori NPs as knowledge holders have been intentional. Although the rōpū is small, their experiences are significant and have maintained a focus on universality as opposed to the general application of findings. However, the insights offered from this study are limited to the experiences of the participants as they were derived solely from Māori NPs attending the NP meeting in Aotearoa New Zealand. Therefore, further engagement is required with Māori NPs in a range of settings and geographical regions. Furthermore, as discussions were conducted online, this may have limited knowledge sharing as Kaupapa Māori research emphasizes physical presence to develop, strengthen and maintain research relationships (Smith, 2021). Our findings highlight the experiences and efforts of Māori NPs, revealing opportunities for organizations to enhance their strategies to address health inequities. These findings represent a progressive step towards integrating cultural and patient safety to achieve Māori and Indigenous health equity.

6.2. Recommendations for further research

Research highlighting the unique contributions of Māori NPs and their capacity for safe care is necessary to continue to elevate the visibility of their work and help clarify the direction needed to achieving health equity for Māori. Research is also required to articulate the role and contribution of all Indigenous NPs, including how Indigenous knowledge not only promotes the health and well‐being of Indigenous communities but also contributes more widely to the culture and leadership of healthcare organizations. There is an imperative to clearly articulate the intersection of patient safety, cultural safety and Indigenous knowledge and to explore how this can be implemented to holistically promote patient safety. Research needs to explore how the experience and knowledge of healthcare practitioners is devalued through managerial systems and standardized metrics, identifying solutions to ensure healthcare is a safe for Indigenous communities and achieves equity.

6.3. Implications for policy and practice

There is a need for healthcare systems to fully embrace and harness the original intent of kawa whakaruruhau and the authentic interpretation and application in practice for everyone. A comprehensive effort from multiple regulatory authorities is needed to ensure the work of Māori NPs is supported alongside better accountability measures. The experiences highlighted by Māori NPs in this study illuminates cultural safety as a key component of competent clinical care not described elsewhere. As hybrid practitioners, it is essential to recognize the cultural contribution of Māori NPs that extend beyond the nursing and medical spheres. Recognition of the value of Māori NPs and concerted efforts by nursing leadership is necessary to support a culturally congruent nursing workforce. We recommend the nursing regulatory authority to enable Māori nurses to implement kawa whakaruruhau as a key component of clinical care which includes culturally safe environments. The nursing regulatory authority also needs to be accountable for accurate interpretation of kawa whakaruruau into a cultural safety framework for all nurses as an obligation to Te Tiriti o Waitangi. Developing appropriate evaluation tools and metrics that accurately capture the full scope of Māori NP practice and its value to patients and communities is necessary. Including Māori NPs at a policy and governance level is crucial to ensure culturally informed measures of patient safety. Achieving safe care can be better realized when Māori and other Indigenous communities are informed, involved, and full partners in policy discussion and care design.

7. CONCLUSION

Using a kaupapa Māori research methodology, we explored the perspectives of Māori NPs on patient safety and identified that patient safety and cultural safety are inherently interconnected in their practice. The insights gained from the NPs emphasize the deep connection between their Indigenous identity and their profession as NPs. Our findings demonstrate that Māori NPs integrate their Māori values, traditions, and knowledge into their daily practice, both consciously and unconsciously, while serving their communities. The seamless weaving of mātauranga and tikanga into clinical practice is essential to any engagement with Māori which relies on a whole of system reorientation.

AUTHOR CONTRIBUTIONS

All authors have agreed on the final version and met at least one of the following criteria: (1) substantial contributions to conception and design, acquisition of data or analysis and interpretation of data; (2) drafting the article or revising it critically for important intellectual content.

FUNDING INFORMATION

This research received no specific grant from any funding agency in the public, commercial or not‐for‐profit sectors.

CONFLICT OF INTEREST STATEMENT

No conflict of interest has been declared by the authors.

PEER REVIEW

The peer review history for this article is available at https://www.webofscience.com/api/gateway/wos/peer‐review/10.1111/jan.16334.

Supporting information

Data S1.

Komene, E. , Davis, J. , Davis, R. , O’Dwyer, R. , Te Pou, K. , Dick, C. , Sami, L. , Wiapo, C. , & Adams, S. (2025). Māori nurse practitioners: The intersection of patient safety and culturally safe care from an Indigenous lens. Journal of Advanced Nursing, 81, 5429–5441. 10.1111/jan.16334

DATA AVAILABILITY STATEMENT

Author elects to not share data.