ABI Rehabilitation New Zealand Promoting the inclusion of indigenous clients with Acquired Brain Injury (ABI) in rehabilitation settings: A model for working with Maori in New Zealand (NZ) Te Miria James-Hohaia (Maori Service Manager) & Emma Weeks (Social Worker) ABI Rehabilitation New Zealand Tena koutou, tena koutou, tena koutou katoa. I’m Emma Weeks and I’m the Social Worker at ABI Rehabilitation in New Zealand. I’ll be talking to you today on our Organisations model for working with Maori in brain injury rehabilitation settings.

The service context IRS is a contract between ABI Rehabilitation and Accident Compensation Corporation (ACC) Catchment area covers over half New Zealand population Age group 16+ years (with individual exceptions) Average length of stay in the service is 35 days New Zealand has a significant geographical expanse, similar to that of the British Isles, with a population of 4.4 million people, who live in towns and cities spread throughout the North and South Islands. ABI Rehabilitation provides comprehensive brain injury rehab services beginning with acute recovery in hospital to reintegration back to home and the community. The Integrated Rehabilitation Service for Traumatic Brain Injury (IRS-TBI) is a service contracted by the Accident Compensation Corporation (ACC), to ABI which operates in the upper half of the North Island and covers over 1/2 of New Zealand’s total population. We are contracted to provide a service to anyone over the age of 16 and our average length of stay is 35 days.

Client Characteristics Ethnicity A review by ABI Rehabilitation of its services identified that 57% of clients were European, 26% Māori and 17% Other. New Zealand based ethnicity analyses have indicated that TBI is more common in Maori as Maori represent only 14% of the total population within the service area. As you can see Māori represent over a quarter of our client group and are statistically over-represented. They are more likely to be younger, have a more severe TBI, and have shorter lengths of stay than their non-Māori counterparts.

Evaluation Underperformance in meeting cultural needs of Maori Rehabilitation too generalised Communication not achieving ideal of being open, honest and transparent Different interpretation of rehabilitation process based on cultural norms Following an evaluation of the IRS (Integrated Rehabilitation Services) contract in 2010 it was identified that there were issues in meeting the needs of Maori clients. Feedback from clients and their family or whanau indicated broadly that although the rehabilitation process was being carried out and the client and whanau participated, the general sentiment was one of dissatisfaction. The rehabilitation processes were too generalised and not specifically tailored to the client, the whanau, or the Maori culture, and that communication between all parties did not always achieve the ideal of being open, honest and transparent. The evaluation report indentified that “One of the key existing challenges for the Service is the varying interpretations between Maori and non-Maori for the definitions of a rehabilitation programme, family, participation and engagement. This mirrors the historical issues surrounding the Treaty of Waitangi: two different interpretations were established via cultural expectations”. It found that the rehabilitation process was sometimes interpreted in two different ways based on differing cultural norms, but with both groups sharing a common goal. It concluded that the model of Service to Maori clients and whanau would benefit from some clarity around the goals that are the most important. (IRS-TBI Special Report 1: Service Outcomes, 2010, p.48) When the contract was extended it included that the service was to develop a Quality Improvement Plan to better address the needs of Maori clients. Te Ara Hou, translated as ‘the new direction’, was consequently developed and described the fresh pathway that ABI Rehabilitation identified for the future; one of unparalleled person centred service to clients with brain injury, as well as the people who support them. ABI Rehabilitation’s bid for accreditation through CARF (the Commission for Accreditation of Rehabilitation Facilities) was also highly relevant to the development of Te Ara Hou. CARF accreditation indicates that a rehabilitation service delivers excellence in person-centred service at all levels of the organisation and the implementation of Whakaritenga Mahi (Maori Services Model) is focussed on this CARF philosophy.

Whakaritenga Mahi Model - Kaupapa (purpose) Based on Maori values that transcends cultures Designed to support non-Maori organisations provide quality services to Maori and their whanau Places the client and whanau at the ‘puku’ of rehabilitation planning, implementation and monitoring Focuses on building relationships. Whakaritenga Mahi was created by Te Miria James-Hohaia, ABI Rehabilitation’s Maori Service Manager, as a practical guide to providing culturally appropriate services specifically designed to support non-Maori organisations to provide quality services to Maori clients and their whanau. It’s based on Maori values that transcend cultures and demystifies areas often seen as difficult. Pivotal to this approach is, placing clients and their whanau at the puku (centre) of rehabilitation planning, monitoring and evaluation. The kaupapa (purpose) behind Whakaritenga Mahi is twofold: Whakaritenga Mahi focuses on implementing Maori models and wellness approaches to better health for our client and their whanau. It encourages Maori desire to be involved in the rehab pathway of their whanau member. In order to improve Maori outcomes it is a ‘whole organisation’ responsibility in the way services are planned and delivered. What’s really important is building and maintaining relationships with the client and their whanau. In order to build good relationships with Maori, we need to: Understand each other’s expectations and aspirations, and Improve processes based on understanding one another’s priorities Engagement starts prior to admission through the completion of a Cultural Services information sheet. This is commonly completed by the ABI hospital based co-ordinator and is discussed with the client’s whanau prior to coming to ABI. Clients, at this very early stage of their recovery, are often unable to take part in this process so it is specifically designed to build the relationship with the whanau rather than the client. It is important to understand those areas that are special to whanau/families and whanau are more likely to engage right from the start because they feel listened to.

Kowhaiwhai (pattern) Embraces unity, teamwork, relationships and collaboration needed to support wellness Encourages and nurtures improved communication The colours represent the different people who bring their expertise to the team Naku te rourou nāu te rourou ka ora ai te iwi This kowhaiwhai (pattern) represents the Whakaritenga Mahi model and symbolizes the mana of all involved in the client’s rehabilitation pathway. The joined up fronds embraces the unity, teamwork, relationships and collaboration needed to support wellness. The fronds facing each other encourages and nurtures improved communication and the colours of the Kowhaiwhai represents the different people who work together to make people well. The intent is to build effective relationships and engagement with all those involved. The whakatauki (proverb) Nāu te rourou naku te rourou ka ora ai te iwi (with your basket and my basket people will be well) provides the foundation of how services are to be provided.

Values Whanaungatanga: The concept of inter-relationships Unity, teamwork, relationships, collaboration, engaging, facilitation, sharing and caring, and working to achieve a common kaupapa. Facilitating collaborative planning Leading, engaging and building relationships. Encouraging participation Drawing on the wider whanau knowledge. Understanding roles and structure of the organisation. Supporting staff potential. Whakaritenga Mahi is based on the following values: Whanaungatanga is the relationship through shared experiences and working together. It embodies the values of teamwork, engagement and building effective connections. Through early engagement, the provision of an appropriate welcome or powhiri and the whanau taking the lead on discussions around identifying tikanga or cultural customs ensures a meaningful start to the therapeutic relationship and one which principally places the client and their whanau at the centre of rehabilitation planning, allowing the client and whanau to exercise their mana and determine what works best for them.

Kotahitanga: The concept of unity, sharing and an understanding in humanity Many voices one purpose Shared vision – common outcomes Working in collaboration to achieve collective potential Joint/shared responsibility and accountability Implementing the Treaty principles of Partnership, Protection and Participation         Kotahitanga translates as unity and equates to the concept of many voices with 1 purpose encompassing a shared vision and common outcomes combined with joint responsibility and accountability. The principles of participation, partnership and protection embodied in the Treaty of Waitangi, a founding agreement signed in 1840 between the British Crown and Maori Chiefs, are brought to the fore and ensure that the client and their whanau are sharing in decision making at every point of the rehabilitation journey.

Demonstrate hospitality through daily practice Manaakitanga: The concept of support, sharing, hospitality and protection Demonstrate hospitality through daily practice Supporting, caring, nurturing relationships Having a warm and engaging approach Providing a safe environment Build trust and a genuine sense of partnership Manaakitanga or kindness is the essence of nurturing relationships through supporting, sharing and caring and in building trust and a genuine sense of partnership in a cooperative, protective and safe environment.

Rangatiratanga: The ‘weaving of people’ Leadership, integrity, respect for self and others Values and ethics, responsibility and accountability Strive to be the best we can Enable and support people to make informed decisions Open to growing the service to meet the need Demonstrate transparency and fairness. Rangatiratanga translates as self-determination, self-management, ownership and leadership. This highlights the importance of integrity, respect and the necessity of providing open and honest information, communicated with a shared language in order to enable and support clients and whanau to make their own decisions and strive to achieve the best for all. As you can see from looking at this value based model its accessible and understandable to all regardless of cultural background and therefore not difficult to put into practice.

Training – initial 3 hour workshop and regular refreshers Increase in cultural knowledge of staff Shift towards whanau being placed at the centre of rehabilitation Better engagement United team approach To ensure ABI rehabilitation staff deliver culturally appropriate services, an initial 3 hour training package to implement Whakaritenga Mahi and 1 hour refreshers are compulsory to all staff. The delivery enables staff to discuss this value based model from a personal perspective and in relation to their work with clients and whanau. Consideration to the model is also given during clinical meetings and family/whanau meetings. A fortnightly Te Reo or Maori Language class also provides staff the opportunity to become familiar with the words, their pronunciation and also the deeper meaning behind them. Whakaritenga Mahi has positively impacted on the way in which ABI Rehabilitation is working with their clients and whanau. There has been a clear shift to whanau being placed at the centre of rehabilitation planning and monitoring, with whanau being considered as the expert in the client and the staff being the experts in brain injury recovery. This united team approach is based on shared values, values which transcend across cultures, therefore not only meeting the needs of Maori clients and their families but all who come into the service. ABI Rehabilitation staff have embraced the training and cultural support provided in order to deliver quality services. This value based model, whilst simple, is easily accessible and understandable as the concepts are shared by every one. Staff have gained an increase in cultural knowledge in which they engage more effectively with Maori as well as non-Maori through the application of these cross cultural values. Overall whanau and clients are positive about the service, feel part of the team and experience the rehabilitation as professional and effective.

Whakatauki (proverb) He aha te mea nui o te ao? He tangata! He tangata! He tangata! What is the most important thing in the world? It is people! It is people! It is people! I would like to finish with a final Maori proverb: He aha te mea nui o tea o? He tangata! He tangata! He tangata! What is the most important thing in this world? It is people! It is people! It is People! Kia Ora. Thank you.

Kia Ora