Cultural competence for physiotherapists: reducing inequalities in health between Maori and non-Maori.

ABSTRACT

The recently implemented Health Practitioners Competency Assurance Act (HPCA Act) has required registration authorities to develop standards for competence that must be met by practitioners. For the physiotherapy profession, the standards provide an opportunity for strengthening understandings and enhancing clarity as to the range of cultural competencies required for safe and effective practice. The Standards potentially provide direction for practical measures that can be taken in everyday practice settings to address ethnic inequalities in health, give meaning to the Treaty of Waitangi, strengthen workforce quality, and address ethnicity as a determinant of health. The latter refers to the extent to which ethnicity has an independent effect on health status due to factors, like racism, impacting differentially across ethnic groups. In order for the potential of the cultural competence standards for physiotherapy to be met it is important that there is a clear understanding among physiotherapists in private and public settings of the meaning, relevance, and value of cultural competence and how to implement it in practice. This paper discusses those issues with reference to addressing inequalities in health between Maori and non-Maori, and draws on the Guidelines for Cultural Competence in Physiotherapy Education and Practice in Aotearoa/New Zealand in identifying a Framework for the implementation of cultural competence in the physiotherapy profession. The Framework is of relevance not only to individual physiotherapists, but also to physiotherapy bodies that have responsibilities for ensuring the cultural competence of the profession. Ratima M, Waetford C, Wikaire E (2006): Cultural competence of physiotherapists: reducing inequalities in health between maori and non-Maori. New Zealand Journal of Physiotherapy 34(3): 153-159.

Key words: cultural competence, cultural safety, Maori, quality, workforce, physiotherapy, inequalities

INTRODUCTION

The recently implemented Health Practitioners Competence Assurance Act 2003 (HPCA) has required health professional registration authorities to develop standards for clinical competence, cultural competence and ethical conduct. For physiotherapists, the standards provide an opportunity for enhancing clarity and strengthening shared understandings as to the range of competencies required for safe and effective practice. In terms of cultural competence, the standards potentially provide direction for practical measures that can be taken in everyday practice settings to strengthen workforce competency and thereby quality, give meaning to the Treaty of Waitangi, address inequalities in health, and contribute to providing an environment that supports culture as a positive determinant of health. While the focus of this paper is on cultural competence as a mechanism to reduce ethnic inequalities in health between Maori and non-Maori, there are other areas of importance such as cultural competence with regard to Pacific populations and other ethnic minorities that are not within the scope of this paper.

THE CONCEPT OF CULTURAL COMPETENCE

The HPCAA came into full force on 18 September 2004 (http://www.moh.govt.nz/hpca). The intention of the Act is to provide a legislative framework to ensure the competence of health practitioners in order to protect the health and safety of the public. Under the provisions of the Act, the registration authorities (including the Physiotherapy Board of New Zealand) were required to develop standards for clinical competence, cultural competence, and ethical conduct which must be met by registered practitioners.

The Act has stimulated efforts across professions to articulate the concept of cultural competence and standards for cultural competence as they relate to the various professional groups. Within New Zealand, the nursing profession has provided leadership in the area of cultural safety (Ramsden, 1992). In distinguishing cultural safety from cultural competence, Professor Mason Durie emphasised that while cultural safety is focused on the experiences of the client, cultural competence has as its primary concern the health workers capacity to improve health status through the integration of culture into the clinical context. He stressed that the purpose of cultural competence is to maximise health gains from the health intervention where the practitioner and client are from different cultures (Durie, 2001).

A recent comprehensive report to the New Zealand Committee of the Australasian Faculty of Public Health Medicine proposed a definition of a culturally competent public health physician, which is equally relevant to physiotherapists. According to the proposed definition, a practitioner will ...

* Recognise their own cultural values and attitudes, and the impact of these on their own practice

* Be aware of cultural diversity and the unique place of Maori in New Zealand

* Function effectively and respectfully when working with people and populations of different cultural backgrounds

* Actively work towards reducing health inequalities for Maori and other cultural groups in New Zealand

* Have the knowledge, attitudes, and skills needed to meet the Cultural competencies set by the ... [registration authority--presuming robust and comprehensive cultural competencies] ..., and

* Demonstrate performance that is consistent with these agreed standards (Mauri Ora Associates, 2005)

The Physiotherapy Board of New Zealand has defined physiotherapy competencies required for entry level registration (The Physiotherapy Board of New Zealand, 1999) and has implemented a recertification programme which requires practitioners to demonstrate continuing professional development to meet competency standards (The Physiotherapy Board of New Zealand, 2004).

The approach taken by the Board has been to subsume cultural competency objectives within broader categories (The Physiotherapy Board of New Zealand, 1999). The standards are expressed at three levels, cultural competencies and associated general learning outcomes and indicators. There is no specific mention of cultural competence in the physiotherapy competency standards, and no competencies specific to cultural competence. It is at the second level, that three General Learning Objectives can be identified that align to the concept of cultural competence--and these are concerned with the Treaty of Waitangi, treating the consumer with respect, and respecting the consumer's rights. In addition, at the third level, an indicator relating to cultural safety is specified.

Using this approach, the cultural competence requirements placed on practitioners are more implied than explicit. The risk with this approach is that cultural competence is marginalised, and rather than being integrated across the range of competencies is narrowly applied within a limited number of general competencies and learning objectives. An alternative two pronged approach is being considered by the Australasian Faculty of Public Health Medicine. A proposed draft of Faculty cultural competencies (Mauri Ora Associates, 2005) introduces three high level cultural competencies that relate to universal cultural competencies, the Treaty of Waitangi and Maori competencies, and ethnic and minority cultural competencies. In addition, the draft recommends integration of cultural competence into the high level practice specific competencies (the equivalent to physiotherapy clinical competencies). The approach being considered by the Australasian Faculty of Public Health Medicine does not change the intent or purpose of the Faculty's current competencies, but rather makes explicit the profession's commitment to culturally competent practice and thereby addressing inequalities in health.

The Guidelines for Cultural Competence in Physiotherapy Education and Practice in Aotearoa/New Zealand were prepared by Taeora Tinana, and ratified at the New Zealand Society of Physiotherapists (NZSP) Annual General Meeting in May 2004. Taeora Tinana is a standing committee of the NZSP (the professional body), which on a voluntary basis undertakes activities to strengthen the profession's contribution to improving Maori health outcomes. According to the Guidelines for Cultural Competency in Physiotherapy, culturally competent physiotherapists integrate knowledge of the Treaty of Waitangi, cultural safety, and Maori health into their practice. Within these three areas practice principles and associated learning outcomes are identified. The Guidelines provide a useful startpoint in any consideration of cultural competence in physiotherapy. Alongside the Guidelines, it would be sensible to continue to take advantage of the investment that has been made by other registration authorities (in particular nursing and medicine, and ACC) in conceptualising cultural competence and drafting comprehensive cultural competence standards that are fully integrated into the physiotherapy competence standards.

THE RELEVANCE OF CULTURAL COMPETENCE TO PHYSIOTHERAPISTS

In considering the relevance of cultural competence to physiotherapists, there are four key areas for discussion; the Treaty of Waitangi, long-standing inequalities in health, enhancing quality care through workforce capacity building, and ethnicity as a determinant of health. The latter refers to the extent to which ethnicity has an independent effect on health status (beyond what can be explained, for example, by economic status) due to factors, like racism, impacting differentially across ethnic groups.

There is a clear Treaty of Waitangi based rationale for ensuring that the potential of physiotherapy to contribute to improvements in Maori health is maximised. The Treaty guarantees the Maori right to good health, through the Article 2 guarantee of protection of those things that Maori consider to be precious (including health) and the Treaty principle of active protection (Durie, 1998). Culturally competent practice provides a mechanism through which physiotherapists can contribute to addressing Treaty of Waitangi responsibilities.

There is overwhelming evidence of the wide, and in some instances increasing, disparities between the health status of Maori and non-Maori (Ajwani, Blakely, Robson, Tobias, & Bonne, 2003). Disparities can be identified in a number of areas of particular relevance to physiotherapy --unintentional injury, cardiovascular disease and respiratory disease. For example, Maori men aged 15 years and over experience unintentional injury hospitalisation rates one-and-a-half times the rate of non-Maori men in the same age group. Maori aged between 5-45 years are more likely to be admitted to hospital for asthma than non-Maori, indicating a more severe experience of asthma. The chronic obstructive pulmonary disease hospitalisation rates for Maori aged 45 years and over were four times the rate of non-Maori in the same age group (RR 4.2, CI 4.1-4.3). Maori were twice as likely to be hospitalised for stroke as non-Maori (RR 2.0, CI 1.9-2.1) (Blakey et al., 2006). Clearly, given the extent of disparities between Maori and non-Maori health in areas of particular relevance to physiotherapy, there is much potential for physiotherapists to contribute to reducing inequalities through culturally competent practice.

The health status disparities are in part a reflection of wide inequalities between the position of Maori and non-Maori in New Zealand society. Maori are disproportionately represented in lower socio-economic groups, indicating that Maori inequitably experience the negative health consequences of lower socio-economic status (Fawcett et al., 2006). The report Decades of Disparity III (Fawcett et al., 2006) explores ethnic and socio-economic inequalities in mortality in New Zealand for the period 1981 - 1999. Findings of the report demonstrate that the over-representation of Maori in lower socio-economic strata accounts for at least half of the ethnic disparities in mortality for Maori of working-age. Therefore, disparities in health status between Maori and non-Maori cannot be fully accounted for by socio-economic inequalities. The implication is that being Maori in itself leads to differential experiences and exposures, such as institutional racism, that put health at risk (Fawcett et al., 2006) and from this perspective ethnicity can in its own right be considered as a determinant of health.

Though there is substantial international evidence of differential access to health care by ethnicity, the literature is less well developed in New Zealand. However, there is evidence of disparities between Maori and non-Maori access to health services. The concept of access, as it is used in this paper, refers to obtaining entry into and through health services in a timely manner and takes into account the resulting health outcome (Cormack, Robson, Purdie, Ratima, & Brown, 2005). According to data from the New Zealand Health Survey 2002/03, Maori adults were more likely to self-report an unmet need for a general practitioner visit in the previous 12 months (20.1% compared to 12.2%). A study investigating Maori coronary artery health care demonstrated that despite Maori age-standardised mortality rates of at least twice that of non-Maori, non-Pacific people, Maori men and women had the lowest rates of both CABG and PCTA at the time of the study (Tukuitonga, 2002). The Cervical Cancer Audit (Sadler, Priest, Peters, Crengle, & Jackson, 2004) identified that Maori women with a high-grade smear were more likely to experience delays in obtaining timely investigation and diagnosis. Maori women were more likely than non-Maori women with cervical cancer to wait for more than the recommended 12 weeks between first high-grade smear and colopscopy, for more than six months between first high-grade smear and diagnosis, and for more than two months between high-grade biopsy and diagnosis. These findings are consistent with strong international evidence of disparities in the receipt of investigations and treatment by ethnicity (Haynes & Smedley, 1999; Shavers & Brown, 2002). For physiotherapists, cultural competence education and training is a mechanism through which the contribution of practitioners to perpetuating inequalities in health can be minimised or eliminated.

In the 2001 census, 2085 individuals identified themselves as physiotherapists. Of that number, 66 indicated that they were Maori. Although Maori make up approximately 15% of the New Zealand population, Maori comprised only 3.2% of physiotherapists. While strengthening the Maori physiotherapy workforce is an important strategy in enhancing the cultural competence of the workforce overall, given the very small numbers it is critical to understand that all physiotherapists have a key role to play in improving Maori health outcomes and reducing inequalities. Strengthening the cultural competence of all physiotherapists is a central strategy, alongside Maori physiotherapy workforce development, for ensuring a quality and representative physiotherapy workforce that is able to delivery equitably for Maori.

THE VALUE AND BENEFITS OF CULTURAL COMPETENCE FOR PHYSIOTHERAPISTS

A central concern for individual physiotherapists and the NZSP is achieving and maintaining the highest quality standards of practice. In the New Zealand context, cultural competence will be critical not only to ensuring the highest possible standard of physiotherapy care, but also in order for the profession to maximise its potential contribution to improving the health outcomes of all New Zealanders, and reducing ethnic inequalities in health. At the level of the individual practitioner, cultural competence enables increased awareness and understanding of the perspectives and lived realities of Maori clients, which in turn facilitates genuine engagement, trust, and information sharing contributing to enhanced clinical outcomes. At the level of the profession, cultural competence provides a vehicle for physiotherapy as a profession to make a strong contribution towards addressing the longstanding ethnic inequalities in health, meeting Treaty of Waitangi responsibilities, addressing ethnicity as a determinant of health, addressing differentials in access to and through health care, and to achieving the highest quality standards.

CULTURALLY COMPETENT PRACTICE FOR PHYSIOTHERAPISTS

Clinical physiotherapy operates in a range of employment settings including private practice, DHBs, private hospitals and rest homes. In all of these settings, in order to operate in a culturally safe manner physiotherapists require an awareness of the cultural context within which they operate as practitioners with their own cultural beliefs, values and practices. Therefore, critical self-reflection is of primary importance. As well, practitioners should acknowledge and have an appreciation of the clients cultural context.

Culturally competent practice relies on the integration of clinical and cultural competencies at each phase of the physiotherapy care continuum. The diagram below identifies phases in a physiotherapy care continuum. The light grey arrows identify points at which cultural competence is required in order to achieve culturally competent practice, and thereby best clinical outcomes. While specific examples from clinical practice are used below in describing cultural competence and a physiotherapy care continuum, it is important to acknowledge the diverse realities of Maori. That is, Maori are not a homogenous group and therefore cultural competence is not concerned with using stereotypes to devise a group of set practices, which once learnt enable the physiotherapist to be culturally competent. Rather, critical self-reflection and understanding the impact of ones own cultural values and beliefs on practice is the startpoint.

Facilitating entry is the first step towards client access to and through physiotherapy care. Facilitating entry for Maori goes much further than a statement that a service is available to all people irrespective of ethnicity. Facilitating entry is an informed process that incorporates awareness of, for example, the diverse realities of Maori so that services may be offered in such a way as to proactively support entry into physiotherapy care. Initiatives to facilitate entry may include proactive measures to raise local Maori awareness of the service and service provision in Maori domains (e.g. marae based ante natal classes, school services, or Maori provider based services). Many Maori are unlikely to be aware that physiotherapy services may be available at no cost, that a general practitioner referral is not required, that it is entirely appropriate to choose to bring whanau support to an appointment, and about the range of services that may be provided by a physiotherapist (e.g. asthma and other respiratory disease treatments). Without this information, Maori may not be accessing physiotherapy care that is, at least in theory, available to all consumers. Facilitating entry also includes providing information about what clients should expect from the service and how they and their whanau may benefit (e.g. an individual may be able to support a niece's kapa haka regionals performance through improved mobility). At the NZSP level, it will be important that future marketing strategies, such as posters and other materials, include Maori perspectives and images in order to appeal to the Maori audience.

Culturally relevant assessment and diagnosis requires an awareness of cultural influences and the capacity to work with clients within their own cultural reality, and therefore the way in which they live their life. An understanding of the influence of historical, social, economic, political and cultural determinants of Maori health will, for example, provide some insight into the barriers Maori face to full participation in New Zealand society and enable a greater degree of empathy. This in turn may provide a stronger basis for rapport and trust, which facilitate enhanced communication for assessment and diagnosis.

Culturally relevant clinical treatment and planning, knowledge transfer, and self management are critical to achieving pest clinical outcomes. The physiotherapist requires the ability, through cultural competence, to gauge a client's priorities in order to determine a realistic treatment plan. For example, it may be unrealistic for the young mother of four children who requires proprioception exercises to take time out of her commitments with children, kahanga reo, or other whanau responsibilities. However, an understanding of her situation may lead the physiotherapist to recommend that she stand on one leg while she brushes her teeth or prepares the dinner. For the koroua who requires an increase in his exercise tolerance, a realistic recommendation may be to park his car at the far end of the carpark each time he visits the marae or supermarket.

Informed referral to a range of health and social services is another important role for the physiotherapist. As health professionals, physiotherapists have knowledge of how to access other services (e.g. general practitioners, occupational therapists, specialists, Maori health providers, social services). In this context it is easier for the practitioner to create links between Maori clients and other needed services. By taking the time to adequately explain service options in terms that are meaningful to the client they are able to make an informed choice with regard to referral. Having an established relationship with other providers will streamline the process. For example, if the physiotherapist is able to develop a relationship of trust with the client and then use personal relationships with other professionals in recommending a needed service it is more likely that service uptake will follow "... yeah, Matt out at WaiHealth is a great guy, he'll look after you, I'll make sure he does". Having that connection, and because the physiotherapist has developed a relationship of trust with the client, would mean that it is more likely that the client will continue this pathway of care.

The end goal in the physiotherapy care continuum is ultimately to assist the client to fully re-integrate into their roles in the whanau/hapu/iwi, workplace, sporting life, and wider community. A culturally competent physiotherapist will have an awareness that the roles of Maori, for example, in terms of family may be quite different from the roles of non-Maori. For example, reintegration into family for Maori may involve a broader range of responsibilities. For example, the female Maori client may see herself not primarily in terms of her role as wife, mother and employee; but also as the niece who provides some care for an elderly Aunty, the Aunty who has an adult nephew living with her, and the sister who has the responsibility to support a sibling's fund raising for touch rugby.

The final element in the care continuum is quality ethnicity data with regard to all aspects of physiotherapy services, as a foundation for physiotherapy care. Culturally competent physiotherapy practice is reliant upon the collection of ethnicity data and access to full information to enable an informed and evidence-based approach. While there may be issues, such as the limited availability of data management software in private practices, it is important to understand the relevance and critical nature of ethnicity data to enable planning to meet the needs of Maori. At the level of the profession, collection of workforce ethnicity data is also critical to initiatives to foster Maori physiotherapy workforce development and therefore the growth of a quality and representative workforce. This emphasises that the purpose of ethnicity data collection is not only to have databases of quality information, but rather that the information is used by individual physiotherapists, services and physiotherapy bodies to improve practice and inform proactive measures to address inequalities in health for Maori.

A FRAMEWORK FOR IMPLEMENTATION OF CULTURAL COMPETENCE IN THE PHYSIOTHERAPY PROFESSION

The development of a culturally competent physiotherapy workforce relies on more than the individual efforts of practitioners to enhance their cultural competency. It requires a profession-wide commitment to, and valuing of, cultural competence to foster an environment that supports the enhancement of individual physiotherapist's cultural competence.

Table 1 below provides a framework for implementation of cultural competence in the physiotherapy profession. The Framework is intended to have particular relevance to physiotherapy bodies (e.g. The Physiotherapy Board of New Zealand and the New Zealand Society of Physiotherapists), as well as to other physiotherapy settings. The Framework identifies eight domains for capacity building to better support cultural competence in the profession --governance structures, policy, guidelines and standards, monitoring and evaluation, workforce, relationships with Maori, funding, and research. Each of the domains has associated strategies, with linked actions. The strategies and actions are not intended to be an exhaustive list, but rather to provide examples of the types of strategies and actions within each domain that if implemented will contribute to developing a professional environment that nurtures and grows the cultural competence of all physiotherapists.

CONCLUDING COMMENTS

Cultural competence is directly linked to health outcomes, and therefore there are clear benefits for the profession in strengthening its cultural competence and thereby the potential for positive health impact. Enhanced cultural competence will enable physiotherapists to better meet Treaty of Waitangi responsibilities and contribute to addressing longstanding inequalities in health, ethnicity as a determinant of health, and differential access to physiotherapy care. Most importantly, strengthened cultural competence will enhance the overall competency of practitioners and the quality of physiotherapy care at every phase of the physiotherapy care continuum. Cultural competence is a core concept underpinning quality physiotherapy practice.

The current review of physiotherapy standards is timely, as there is much potential to draw on the ratified Guidelines for Cultural Competence in Physiotherapy Education and Practice in Aotearoa/New Zealand as well as the extensive work in the area of cultural competence that has recently been carried out by other professions. While there is an opportunity to benefit from the investment made by other professions' registration authorities, it will be critical that The Physiotherapy Board of New Zealand also invest in recruiting local expertise to assist in the development of specific physiotherapy cultural competencies to be included in the competency document, and as well seek advice as to how the clinical competencies may explicitly incorporate a cultural competence component. It will be critical that the standards fully integrate the principle of cultural competence if they are to be of most value to the profession.

Importantly, the onus for cultural competence is not only on the individual physiotherapist, but the profession as a whole and therefore key physiotherapy bodies. The Framework for Implementation of Cultural Competence in the Physiotherapy Profession provides guidance as to the domains of influence, and strategies and actions in each of those domains that may contribute to providing a supportive environment for cultural competency in physiotherapy.

Embedding the principle of cultural competence within the physiotherapy profession will require a developmental approach. However, in the context of the current review of standards there is right now an ideal opportunity to strengthen the profession's competency framework. This in turn will better ensure that current and future physiotherapists are positioned to achieve their maximum potential as clinically, culturally, and ethically sound health professionals who not only make a difference to improving health outcomes but also to reducing ethnic inequalities in health.

REFERENCES

Ajwani S, Blakely T, Robson B, Tobias M and Bonne M (2003): Decades of disparity: ethnic mortality trends in New Zealand 1981 1999. Wellington: Ministry of Health.

Blakey K, Walls H, Harris R, Rippon R, Yeh L-C, Huang K, et al (2006): Tatau kahukura, Maori health chart book 2006. Wellington: Ministry of Health.

Cormack D, Robson B, Purdie G, Ratima M and Brown R (2005): Access to cancer services for Maori. Wellington: Te Roopu Rangahau a Eru Pomare, University of Otago and Auckland University of Technology.

Durie M (1998). Whaiora: Maori health development (2nd ed.). Auckland: Oxford University Press.

Durie M (2001). Cultural competence and medical practice in New Zealand: a report to the Australia and New Zealand Boards and Councils Conference, Nov 2001. Palmerston North: Massey University.

Fawcett J, Blakely T, Robson B, Tobias M, Harris R and Pakipaki N (2006): Decades of disparity III: ethnic and socio-economic inequalities in mortality, New Zealand 1981 1999. Wellington: Ministry of Health.

Haynes M and Smedley B (Eds), (1999): The unequal burden of cancer: an assessment of NIH research and programs for ethnic minorities and the medically underserved. Washington DC: National Academy Press.

Health Services Research Centre/Te Hikuwai Rangahau Hauora. (2005). Assuring medical practitioners' cultural competence: a discussion document produced for the Medical Council of New Zealand. Wellington: Victoria University.

Mauri Ora Associates. (2005). Towards cultural competency for public health medicine--a discussion paper May 2005. Auckland: Mauri Ora Associates.

Ramsden I (1992). Kawa whakaruruhau: guidelines for nursing and midwifery education. Wellington: Nursing Council of New Zealand.

Sadler L, Priest P, Peters J, Crengle S and Jackson R (2004): The New Zealand cervical cancer audit: whakamatau mate pukupuku taiawa o Aotearoa (Screening of women with cervical cancer: 2000-2002). Wellington: Ministry of Health.

The Physiotherapy Board of New Zealand (1999): Registration requirements: competencies and learning objectives. Wellington: The Physiotherapy Board of New Zealand.

The Physiotherapy Board of New Zealand (2004): Recertification guidelines: guidelines for continuing professional development for physiotherapists, from http://physioboard.org.nz/

ADDRESS FOR CORRESPONDENCE

Assoc Prof Mihi Ratima, Taupua Waiora, Centre for Maori Health Research, AUT University. Email: [e-mail]

Mihi Ratima

Associate Professor, Taupua Wairoa, AUT University

Cathrine Waetford

Erena Wikaire

Taupua Waiora, Centre for Maori Health Research

AUT University

Table 1. A Framework for Implementation of Cultural Competence in the
Physiotherapy Profession

Domains         Strategies                   Actions

Governance      Formal mechanisms to         Designated Maori positions
structures      ensure Maori participation   on key physiotherapy
                at all levels of key         bodies and associated
                physiotherapy bodies         committees--NZSP, New
                                             Zealand College of
                                             Physiotherapists, The
                                             Physiotherapy Board of New
                                             Zealand Mechanisms
                                             developed to support
                                             Taeora Tinana input into
                                             governance structures

Policy          Policy linked to known       Physiotherapy policy
                Maori health policy          reviewed in terms of
                frameworks (e.g. He          reducing inequalities
                Korowai Oranga)              Cultural competency
                Policies integrate the       position statement
                principle of reducing        developed
                inequalities                 Evidence-based
                                             documentation of
                                             rationale, value, and
                                             outcomes for cultural
                                             competency

Guidelines      Guidelines and standards     Cultural competencies
and             be revised to explicitly     identified and included in
standards       identify cultural            physiotherapy cultural
                competencies, and fully      competence standards with
                integrate cultural           associated learning
                competence                   outcomes and indicators
                                             Cultural competence
                                             explicitly integrated into
                                             clinical competencies
                                             Guidelines for cultural
                                             competence used as
                                             startpoint in revision of
                                             overall standards

Monitoring      Ethnic data routinely        Explicit and specific
and             collected (client and        cultural competence
evaluation      workforce data)              evaluation and monitoring
                Robust mechanisms            process developed
                developed to monitor         Methods and tools to
                cultural competence          assess cultural competence
                                             Maori expertise in
                                             development of monitoring/
                                             evaluation capacity
                                             NZSP enhances ethnic data
                                             collection processes

Workforce       Strengthen the Maori         Communication strategy for
                physiotherapy workforce      the profession regarding
                Strengthen the               the benefits of cultural
                physiotherapy workforce      competence
                cultural competencies        Workforce development
                                             needs analysis and
                                             planning carried out
                                             Review degree curricula of
                                             Schools of Physiotherapy
                                             in terms of cultural
                                             competence
                                             CPD activities required to
                                             include integrated
                                             clinical and cultural
                                             competence elements, which
                                             include practical
                                             activities

Relationships   Strengthened relationships   NZSP establish
with Maori      with Maori stakeholders      relationships with Maori
                                             health professional bodies
                                             Taeora Tinana supported to
                                             develop relationships with
                                             Maori stakeholders
                                             Schools of Physiotherapy
                                             establish formal and
                                             meaningful relationships
                                             with Maori stakeholders

Funding         Increased investment in      Local experts in cultural
                Maori health outcomes        competence funded to
                Maori analysis/              provide comprehensive
                perspectives in all funded   advice regarding
                initiatives                  physiotherapy cultural
                                             competencies

Research        Research to include a        Physiotherapy bodies
                focus on reducing            support and advocate for
                inequalities                 research to address health
                Research to produce          inequalities
                evidence-base for physio     Advocate for research to
                cultural competencies        strengthen the
                                             evidence-base for
                                             physiotherapy
                                             competencies.