Negotiating Health Equity in Aotearoa New Zealand: A Constructivist Grounded Theory of IQNs’ Balancing Perspectives and Reconciling a New Understanding

Abstract

Introduction Health inequities are avoidable, unfair, and unjust health outcomes experienced by some people in New Zealand. Given the colonial history of New Zealand and repeated breaches of Te Tiriti o Waitangi, the Indigenous Māori population is one of the major groups that suffer persistent health inequities in New Zealand. Internationally Qualified Nurses (IQNs) represent over a third of New Zealand’s nursing workforce, arriving in New Zealand with diverse cultural backgrounds and worldviews shaped by their countries of origin. These worldviews influence how they perceive, interpret, and engage with the concepts of health inequities in New Zealand.

Background Many IQNs arrive with limited knowledge of the sociopolitical foundations of New Zealand’s health system. Orientation and training programs, including the now-defunct Competence Assessment Program (CAP), have been found to vary in quality and depth, often failing to equip IQNs with the tools to engage critically with equity-related concepts. This study explores how IQNs construct their understanding of health inequities, drawing on their lived experiences in New Zealand’s healthcare system.

Methodology and Methods This qualitative study employed a constructivist grounded theory (CGT) methodology to explore how IQNs construct their understanding of health inequities in New Zealand. Six IQN participants, with at least 2 years of nursing experience in New Zealand, were recruited through purposive and theoretical sampling. Data was collected through semi structured interviews. Analysis involved initial and focused coding, constant comparison, memo writing, and theoretical sampling, all of which followed the tenets of CGT.

Findings The core process of constructing understanding around health inequities by the IQNs was identified as “negotiating,” a dynamic and context-dependent process. Two broad interrelated categories emerged from the findings: reconciling a new understanding and balancing perspectives.

In the first category, IQNs negotiated meaning by encountering and engaging with equity-related practices and educational resources, utilising self-directed learning, peer interactions, and formal training to question and reflect critically on their learnings and practice. In this category, the IQNs negotiated new learnings, making sense of unfamiliar ideas and gradually developing new insights through meaning-making.

In the second category, the negotiating process deepened as IQNs were confronted with tensions between their beliefs in treating everyone equally and the structural framing of equity in New Zealand, especially in the light of Te Tiriti o Waitangi. This often led to cognitive and emotional conflicts, particularly around ideas such as individual accountability for health. As IQNs attempted to reconcile these opposing frames, the process of negotiating extended beyond learning into value-based reflection.

Variation in negotiating was evident across participants based on the nature of their prior exposure to sociopolitical issues, professional roles, exposure to inequities in their workplace, and access to learning opportunities. Some IQNs negotiated these tensions by engaging in deeper reflection and actively aligning their perspectives with equity principles, whereas in others, it led to disengagement and unresolved tensions.

Discussion Rather than framing equity knowledge as present or absent, this study positions IQNs as active agents who construct their understanding of equity-related concepts by negotiating between their lived experiences in New Zealand, which are shaped by their prior worldviews, abilities to reflect critically, and the systemic context. The study highlights how IQNs enter the New Zealand workforce with diverse worldviews and struggle to understand the difference between equity and equality. The Western biomedical model still dominates the New Zealand healthcare system, and in many organisations, cultural safety policies are not reflected in practice. Additionally, the preceptors are often unprepared to assist the IQNs in navigating the complex transition into the New Zealand healthcare system. The study reveals the need for orientation programmes to facilitate reflective engagement and for organisations to promote mentorship models to support IQNs in their complex transition to New Zealand, enabling them to construct equity-related knowledge effectively.

Conclusion This research provides an emergent grounded theory of “negotiating,” a theoretical model that captures how IQNs construct understandings of health inequities in New Zealand. It offers a new conceptual lens that has implications for improving orientation programmes, professional development, and policy design to ensure IQNs actively engage in mitigating health inequities in their daily practice.