Te Paatu o Te Ao Hurihuri – pandemic-related virtual adaptation of an established marae-based workshop for rural doctors: a qualitative study
Katharina Blattner
1 2 * , Marara Rogers-Koroheke 2 , Lynne Clay 1
1
2
Abstract
Due to COVID-19 pandemic restrictions in Aotearoa New Zealand, an established remote community marae-based workshop (a component of a postgraduate rural medical programme) was converted into a virtual platform.
The aim of this study was to explore student and teacher experiences of this virtual adaptation with focus on cultural aspects.
A qualitative exploratory study was undertaken that involved document review and qualitative interviews. Students and teachers were invited to participate. Semi-structured interviews were conducted. Thematic analysis was undertaken using a framework-guided rapid analysis method. The two participant groups’ data were analysed concurrently but separately.
Students found the virtual workshop valuable in furthering their knowledge of Māori culture, cross-cultural communication skills and health inequities in rural clinical practice. Through the innovative efforts of their teachers, they felt some sense of connection with the remote locality and its people. Teachers were able to impart knowledge, connect and keep everyone culturally safe through their commitment and adaptability. However, moving to a virtual platform meant compromise to the cultural experience for students and loss of sharing the learning and experience with their place and their people.
In the event of a further pandemic or other emergency situation, where strong established relationships exist, replacing an in-person remote marae-based workshop with a virtual workshop, while limited, is achievable and has value. When urban tertiary institutions partner with remote Māori communities to deliver virtual teaching, caution is needed in ensuring sustained transparency in priorities and expectations to avoid further exacerbations of power imbalance and resulting loss of value.
Keywords: community engagement, community-oriented partnership, COVID-19 pandemic, distance education, Māori health, postgraduate medical education, rural and remote health, rural health workforce.
| WHAT GAP THIS FILLS |
| What is already known: The COVID-19 pandemic has led to further emphasis on distance education as the solution for education for rural health professionals remote from major centres and training to work in rural areas. |
| What this study adds: This research considers the value of and the important limitations for both students and teachers in the virtual adaptation of a culturally focussed educational workshop in a remote marae setting for postgraduate rural medical trainees. |
Introduction
In Aotearoa New Zealand (NZ) rural residents have poorer health outcomes than those living in urban areas, and this is accentuated for Māori, the indigenous people of NZ.1 It is estimated that around 19% of New Zealanders rely on rural health services and rural health professionals.2
Despite the growing body of literature concerning the impact of the coronavirus (COVID-19) pandemic on medical education3 less is known about its impact on rural-targeted training. An Australian study of medical undergraduates undertaking rural-community virtual placements during the pandemic found the virtual format more accessible but less effective than in-person at delivering ‘heart and hands’ learning.4 New Zealand postgraduate rural vocational trainees have expressed concerns about pandemic-related loss of opportunities for cross-cultural learning through place-based immersion, particularly important in view of the known health disparities for Māori.5,6
The University of Otago’s (UoO) mainly distance taught postgraduate GENA725 academic module, Communication in Rural Hospital Medicine (hereafter G725), is a component of the Royal New Zealand College of General Practitioners national Rural Hospital Medicine (RHM) training programme.7,8
The overall aim of the 6-month module is to increase awareness of one’s own culture and internal bias to improve cross-cultural interaction and health inequities in clinical practice.9 The module includes communication and cultural safety, with the definition of the latter aligning with that generally accepted in the NZ literature.10
Since 2006, the mandatory 4-day G725 workshop has been held on a rural marae (Māori meeting house), hosted by the local health service, Hauora Hokianga and the Hokianga community.11 There is an established partnership both at the individual and institutional level in delivering the immersive workshop. Local staff are involved in teaching and UoO convenors have local clinical roles. Feedback from UoO students over more than 15 years has consistently emphasised the importance of the marae immersion component in conveying the essence of Te Ao Māori (Māori world perspective) and tikanga (the customary system of values and practices) and how these relate to clinical care.
In 2022, due to pandemic restrictions, the immersive workshop was converted into a virtual format, ensuring that students could continue their studies. The established teaching team committed to this while cautioning that conveying the essence of Te Ao Māori on a screen, without the warmth of a marae setting and input from the community, would bring new challenges in workshop delivery. The aim of this study was to explore student and teacher experiences of the virtual workshop, with a focus on cultural aspects.
Methods
Document review and informal discussion
To provide background and context in understanding the virtual workshop preparation, informal discussions were conducted with the teacher-host team (UoO and Hauora Hokianga), and relevant email correspondence from 3 months prior to the workshop was reviewed chronologically.
Qualitative interviews
All 13 students enrolled in G725 were invited to participate in an online semi-structured interview. Respondents provided demographic information. Interviews were conducted by an experienced qualitative researcher not involved in teaching (LC). The interview schedule explored participants’ experience of the virtual workshop focussing on cultural aspects. Interviews were recorded using Zoom’s automatic recording service (2022, https://www.zoom.us/). Immediately following interviews, to facilitate rapid analysis, the interviewer wrote a short summary (memo) using audio playback and auto transcriptions to check for accuracy. Interviews averaged 17 min in duration.
All seven teachers were invited to participate in a semi-structured interview. Respondents provided demographic information. Interviews were conducted in-person in Te Reo (Māori language) and English by a Māori health researcher (MR) experienced in qualitative methods and well known to participants. The interview schedule explored participants’ experience of delivering the virtual workshop. Interviews were recorded and auto-transcribed using the Otter.ai transcription tool (2022, https://www.Otter.ai). To facilitate rapid analysis, immediately after interviews a summary (memo) was completed by the interviewer using audio playback including English interpretation of Te Reo Māori terms to conceptualise accurately the intent of conversations. Interviews averaged 55 min in duration.
A framework-guided rapid analysis was undertaken.12 A structured template was developed that was used to categorise data according to the study question guide. Two researchers reviewed each audio-recording, memo and framework independently, following which an iterative process to converge and corroborate findings was undertaken. Analysis of data from all teacher participants was led by MR. Categories were then discussed within the team to seek consensus, and themes formulated. The two participant groups’ data sets were analysed concurrently but separately. Preliminary results were shared in the form of a report with participants and feedback sought.
Results
Chronological narrative
Once it was clear the marae workshop could not go ahead, staff pivoted quickly to virtual format planning. Planning between UoO and Hauora Hokianga staff occurred through regular emails. Weekly videoconferences provided a chance for the team to reconnect and finalise logistics. Well in advance, ensuring timely postal delivery across NZ, staff crafted and sent kete rongoa (basket of Māori traditional plant remedies) to each student.
UoO convenors were physically present in Hokianga a week before the workshop, checking technology set up and providing tailored support for staff.
Qualitative interviews
Of 13 students invited, six (46%) agreed to participate (see Table 1 for student characteristics).
| Participant characteristics n = 6 | ||
|---|---|---|
| Gender | ||
| Female | 3 | |
| Male | 3 | |
| Age in years (Median, IQRA ) | 42 (18) | |
| Ethnicity | ||
| Māori | 1 | |
| Non-Māori | 5 | |
| Previous marae experience | ||
| Yes | 3 | |
| No | 3 | |
| Rural workplace during study | ||
| Yes | 4 | |
| No | 2 | |
Participants were designated a number (1–6) and were referred to throughout the study by this coding. Four main themes were identified: Expectations; Value; Sense of connectedness; and What was lost. Illustrative participant quotes are presented in Table 2.
| Theme | Quotation | |
|---|---|---|
| Expectations | I was looking forward to the experience of the being part of a marae, I guess, when initially signing up, that was one of the main things. It was what it was … quite appropriate, really, you make do with what you’ve got, and you do the best with where you’re at, and get the most out of it. (P1) | |
| I was quite relieved because of the time involved in travelling and the financial pressure of trying to organise … I’m not very good at communal living, so that would have been a challenge for me. Didn’t have to worry about that. It was a sort of a bit of anxiety that I could put to one side. (P4) | ||
| Value | If I can take the vibe from the residential where I could see that there was a much more directed effort [at Hokianga] to improve the health of Māori populations … if I can carry that on with me in some way big or little, then I would be glad. (P3) | |
| I learnt a lot. It changed my practice and my understanding. The culture, in this depth – I will be more prepared when dealing with death in different cultures especially Māori, more prepared. (P2) | ||
| … whanaungatanga (close connection between people) … you can watch people’s brains tick over … to an understanding, or perhaps even a willingness to entertain a different perspective? (P6) | ||
| Sense of connectedness | … all the different people that were involved in it. We didn’t just get one person slant on things. We got lots of different people’s ideas around it which I think is great. (P1) | |
| Just the care that had been put into it was quite amazing. I just was quite blown away by it really … I think that had a lot to do with setting a really positive tone of people inviting you and showing you something special from the area. (P4) | ||
| … the rongoa, the smell of the medicine, actually having a parcel being delivered from Hokianga. Yeah, you see all these different types of medicine, the notes, what its used for how its prepared … all that richness of culture is there. (P5) | ||
| What was lost | … it’s a ‘kanohi te kanohi (eye to eye) thing’- it’s better than nothing but it’s not the real thing. Intangible things don’t translate – what happens when you’re having a conversation with someone while washing dishes, what happens in the wharenui (communal place of marae) after everything is said and done, watching other peoples’ cultural practices around their daily activities. (P6) | |
| You kind of lose some of the essence of the culture across a zoom … some of the more spiritual element of it … you know, Māori culture is so tied into land, then we should be there amongst their land … being like grounded and present in that environment. (P3) | ||
| It probably influences the … perception of rural medicine somewhat … by going to a rural place and spending the time, upskilling … it’s probably more valuable than … everybody going to the city. (P4) |
Participants were aware a virtual workshop would not be the same as in-person but expected it would fulfil UoO requirements. While a virtual format was familiar to participants after 2 years of pandemic restrictions, all expressed disappointment as the marae experience was considered the most important part of this module and was also unique within their wider academic programme.
Some participants voiced relief that they would not be required to undertake travel, at the same time they acknowledged they would be pushed less out of their comfort zone if not required to travel and be on the marae.
Participants reported furthering their knowledge and understanding of Māori culture and health disparities and gaining skills in communication as well as insights into rural health services. Several participants reported that learnings had subsequently influenced and changed their clinical practice. Many were surprised at the depth of learning possible.
Participants valued the workshop’s culture of equity, providing a glimpse into Te Ao Māori, an experience different from previous teaching environments. Their view was that the virtual workshop, despite limitations, still had the power to change minds.
The use of Te Reo Māori, karakia (prayer), collective teaching and narratives, created a thread crossing through the workshop, connecting sessions including those with a specific clinical focus. In this way a sense of connection was created. One participant mentioned experiencing ‘warmth’ across the screen. Teachers gathered on site, rather than each in their own separate place and videoconferencing window, with a marae-style backdrop giving a strong sense of togetherness and a genuine flow to conversations. The kete rongoa parcel delivered to each student’s home was a highlight for many, a connector to Hokianga, a shared experience, something real to smell and hold.
Participants described the connection to the place and the people in the virtual format as a very diminished sensory experience. They missed warmth, an atmosphere of togetherness, the sharing of food, the cup of tea. Some discussed how informal aspects would be more important than formal teaching. Participants discussed the importance of being physically in the place, on the land and how the absence of this might affect their learning.
Some participants felt the journey they would have had to undertake to get to the workshop was, in itself, an important loss. As postgraduate trainees in rural medicine, seeing the changing landscape, ‘undertaking the journey’ would mean real exposure to the rural context.
All staff invited agreed to participate (n = 7, 100%). One interview was by videoconference, the remainder were in-person in Hokianga. Three were individual interviews, two involved two participants. Participants were designated a number (7–13) and were referred to throughout the study by this coding. Participant characteristics are shown in Table 3.
| Participant characteristics n = 7 | ||
|---|---|---|
| Gender | ||
| Female | 5 | |
| Male | 2 | |
| Age in years (median, IQRA ) | 58 (21) | |
| Ethnicity | ||
| Māori | 5 | |
| Non-Māori | 2 | |
| Length of prior involvement in residential | ||
| > 10 years | 5 | |
| 6–10 years | 1 | |
| 1–5 years | 1 | |
Four themes were identified: Conveying Te Ao Māori – commitment; Imparting our tikanga – connecting; What was lost – compromise; and Apōpō (tomorrow). Illustrative participant quotes are presented in Table 4.
| Theme | Quotation | |
|---|---|---|
| Conveying Te Ao Māori: commitment | … the fact that it’s [the workshop] actually happening, that it hasn’t been swept away as if it was never important in the first place. Maybe you can’t do it as well as you would have done it in a marae setting. But you try and approximate something that … emphasises the value of knowing something about biculturalism in NZ, and ways of communicating with other cultures. In particular, what are the elements [for clinicians] that are important to know about? (P11) | |
| Through virtual training we were able to cater [to the need] … and we stayed focussed on our objective. (P9) | ||
| Imparting our tikanga – connecting | [name of teacher] managed to create that atmosphere that said we were in one place … it was you know … his connecting work all the time … doing karakia (prayers) in the morning between sessions … that was invaluable in terms of creating that sense of connection … there wasn’t just a discontinuous set of lectures, he sort of provided a marae experience if you like. (P11) | |
| … we had our own little community … we developed a feeling of relationship anyway. That was one of the values of having the three of us together because … I might use a term and I think, ‘well, it’s not necessarily self-evident to me, therefore, it’s worth teasing that one out’. And I think that is one of the real values of having a panel as opposed to being in separate spaces. (P11) | ||
| Tikanga protocol was followed, students felt safe in the teaching virtual place. (P10) | ||
| What was lost – compromise | … we were unable to bring the world from outside into Hokianga. (P8) | |
| It was awkward because you don’t have the feeling of being in the same room. Not the true essence of a hui (meeting), no sharing of kai (food), korero (discussion). You don’t get the feeling of the ahua (character) of the person (P13) | ||
| Compromising Māoritanga (Māori culture). Really, you know, we’re doing our best for the sake of getting some instruction to the docs, but at the cost of our own culture? (P7) | ||
| Apōpō (tomorrow) | You can’t beat a kanohi ki te kanohi (eye to eye) … you can’t compare. Our tikanga and our cultural practice can be inhibited on zoom. (P13) | |
| … the marae workshop starts with nga tauira (students) weaving their way through our expansive vista which is Hokianga. A spiritual experience to arrive at the marae where the spirit of the occasion follows through. There is no comparison with virtual. (P7) | ||
| If there was no Covid in front of us, there is no excuse: we should have kanohi kitea (face to face). (P9) |
Participants described putting anxieties and doubt aside as they committed to convey Te Ao Māori relevant to G725. Virtual teaching was likened to conversing with ‘tauira (students) on the paatu (wall)’.
Participants explained how the importance of the teaching of cultural understanding was as much about the need to honour their genealogy as it was about the learning for students.
The commitment of the team was to convey the importance of communication and knowledge of Māori culture as an essential part of being a doctor in NZ. Tikanga was, for participants, a way of being throughout their lifetime, the relevance and sharing of tikanga was the need to know, to understand and to be inclusive. Thus, the onus was on them as a team to share their knowledge, and if the marae workshop was not possible then virtual was next best. It was about doing the right thing and doing things right.
Participants described how they went about creating a sense of connection virtually. First, there was the gift, kete rongoa, sent to students before the workshop as an expression of welcome. Then, in real time, creating a feeling of belonging through the connecting work of karakia (prayer) and discussion between sessions.
Participants described how a vision of togetherness in the team was crafted, with two or three teachers in a single videoconferencing window seated together with a local backdrop, sharing and discussing with each other and the students.
More formality and structure were needed to engage students virtually as opposed to on-marae, but by working together, not only in preparing content carefully but also paying constant attention to technical aspects, participants saw that the task which had seemed daunting, was achievable.
Participants discussed what was lost, not only for the students but also for the teachers and wider community, emphasising the loss of physical interaction, karakia, waiata (songs) and katakata (laughter), that would normally be experienced on the marae. Sharing meals, kitchen chores and sharing stories.
It was not just being on the marae, it was the marae and the people of the marae and the communal living style, which enabled relationship building, that couldn’t be captured on the screen. By not being immersed, students lost the opportunity of building memories and cementing relationships, and the community lost the opportunity of sharing in the experience.
Participants discussed compromise to their culture and to the cultural experience for students in the virtual format where the true essence of Te Ao Māori was constrained.
Participants also mentioned the loss for students of journeying to the place of the residential, noting that some students had never previously ventured to their region of NZ.
Participants agreed that while it had been the right decision to have managed the delivery of G725 on the paatu, this was not ideal, ‘not tika’ (correct).
For participants, Te Ao Māori was best shared kanohi kitea (face to face) and in a place of cultural safety as an immersive experience from the very beginning, including the journey from the student’s home to the marae workshop and back home.
Participants were clear that future marae immersive workshops must be upheld, viewing a move to virtual format, except in an emergency situation like the COVID-19 pandemic, as indefensible.
Discussion
Summary of study findings
For students, the virtual workshop met expectations for pandemic conditions, was well planned and furthered their knowledge and understanding of Māori health, inequities and culture in the rural clinical context. Through the preparatory and in-session innovative work of the local teachers, students felt a sense of connection while recognising the virtual format limitations.
Teachers, through their commitment and flexibility and with strong technical support, were able to impart knowledge, connect and keep everyone culturally safe. However, moving ‘to the paatu’ meant compromise to their culture and to the cultural experience for students, and loss of sharing the learning and experience with their marae and people.
Comparison with existing literature
The study concurs with and extends previous research that, during the COVID-19 pandemic, virtual adaptation of an immersive culturally focussed workshop for rural doctors can be acceptable and of value.4,5
Given what is known in NZ regarding rural Māori health inequities,1,6 and that the students concerned were doctors training for work in rural and remote NZ communities, this is not insignificant.
In accord with previous findings, underlying the success of this virtual adaptation was a well-established relationship between the tertiary institution (UoO) and the community organisation (Hauora Hokianga) in delivering the immersive workshop, at both institutional and individual levels.4,5
Local teachers in this study brought into the virtual classroom their language (Te Reo Māori) and a culture that was ‘of the local community’, both features that have been identified as key to immersion learning.13 The physical gift of traditional medicines sent to students, contributing to a sense of connection, was an added innovation that enhanced the sense of connection in the virtual context. Māori innovation and adaptation within digital technologies for educational purposes is well established.14
In moving the immersive workshop to a virtual format, UoO and vocational training programme requirements for students were met. However, study findings also emphasise the resultant loss of the shift in power balance usually accompanying the G725 marae-based workshop. Students were not required to step out of their comfort zone on the ‘journey North’ and into the Te Ao Māori world, and they were already familiar and comfortable with a UoO virtual learning format. In contrast, for teachers at home in Hokianga, not only was the virtual platform less familiar, but their teaching was stifled and compromised by the absence of and disconnection to their marae, place and people.
Study findings emphasise the importance in a partnership between a large tertiary institution and small rural community, of careful and sustained nurturing of the relationship particularly in emergency situations (such as the COVID-19 pandemic) which may demand rapid changes in delivery of teaching. Care must be taken that adaptations to virtual platforms, even if temporary, don’t create and reinforce inequities. Clarifying roles, expectations and priorities whilst explicitly recognising that these may not always align, would strengthen such a relationship and the resultant co-delivered teaching.
Strengths and limitations
The study was Hauora Hokianga and UoO led, the collaboration being a strength. A known local Māori researcher, embedded in the community and culture, led the teacher interviews and analysis, with different results likely had this not been the case. It is possible that in the process of interpretation of teacher interviews conducted in Te Reo Māori into English, some richness of data was lost.
A limitation was the low response rate from students. We cannot know if the views of the six students who responded (of the 13 invited) differed from those who did not, though the demographics of the study participants were representative of the UoO postgraduate rural module cohorts.
Implications for practice and research
In the NZ context, it is important that limitations of virtual workshops pertaining to cultural teaching and community engagement, as highlighted in this study, are recognised by the urban-based institutions from which rural health professional training programmes are currently delivered. If the substantial potential benefits of community engagement in rural health professional education15,16 are to be sustained and strengthened, then close attention must be paid to community partners’ voices regardless of emergency situations such as the COVID-19 pandemic.
Further research should be undertaken to build on these study findings of adapting experiential learning methods using indigenous, collaborative and community-led research approaches.
Conclusion
In the event of a further pandemic (or similar emergency situation), where strong established relationships exist, replacing an in-person marae-based community workshop with a virtual workshop, while limited, is achievable and has value. However, careful consideration must be given to acknowledging and, where possible, addressing its limitations.
Acknowledgements
The authors thank the staff of Hauora Hokianga and the wider Hokianga community for their support and acknowledge their ongoing contribution to the education of rural health professionals in Aotearoa New Zealand.
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