What Impacts Implementation of Tikanga Ako Hono-Tāngata / Relationship Centred Practice by Allied Health Professionals within Hawkes Bay District Health Board?

Abstract

Tikanga Ako Hono-Tāngata, or relationship-centred practice (RCP), is an Aotearoa New Zealand approach to practice developed at Hawkes Bay District Health Board (HBDHB). It weaves together principles of person-centred care (PCC) and Te Ao Māori engagement approaches. Anecdotal feedback from health professionals who have undertaken the RCP training indicated they found it challenging to embed and sustain this relational way of working. This doctoral research sought to understand allied health practitioners’ experiences of embedding RCP into their clinical practice, to explore what helped or hindered the implementation of RCP, and to develop rich understandings of what is required for health professionals to sustain this way of working.

Using interpretive descriptive methodology, semi-structured interviews were completed with eight purposefully sampled allied health professionals (AHPs) from across disciplines and practice contexts. Data were analysed using reflexive thematic analysis. Following preliminary analysis, participants participated in a focus group to sense check if preliminary findings resonated, test assumptions, and generate a collective social knowledge from their shared perspectives. A key informant group was established, including programme facilitators who were clinical practitioners and cultural advisors, and assisted me to engage reflexively with my data and interpretation, further supporting theme development and refinement.

Three themes were constructed. The first theme talks to the structural and systemic factors which impacted the implementation of RCP. The prevailing norm of valuing workflow and expediency over practicing RCP often compromised a clinician’s sense of agency or control over one’s actions. The second theme provides insight into the challenges of using RCP in everyday practice which commonly resulted in internal tension for clinicians. This manifested in three distinct ways. First, when clinicians took time to find out what was important to the patient and agree shared goals, clinicians were sometimes unable to meet these expectations due to factors outside of their control. Second, there could be a lack of alignment between the clinician’s disciplinary and evidence-based knowledge and patient choice. Third, some clinicians perceived a tension between their discipline-specific norm of providing practical hands-on treatment and the ethos of taking the time to engage with the patient. The final theme illustrates how positive experiences of using RCP strategies empowered and enabled clinicians to be confident and motivated to continue to use those strategies and embed RCP in a more fulsome way into their practice, particularly when using Te Ao Māori approaches.

The research identified three original contributions to advance practice knowledge. The first contribution provides insight into change programmes needing to take into account the divided sense of responsibility clinicians have to whaiora, the organisation, and their discipline-specific practice norms. This divided sense of responsibility impacts clinicians’ ability to prioritise relational practices. The second contribution talks to the need for an overarching organisational change programme in Aotearoa New Zealand when introducing initiatives like RCP to ensure uptake and sustainability. It is imperative to partner with cultural experts and apply Indigenous change frameworks in the design, implementation and evaluation phases to honour our commitments to the articles of Te Tiriti o Waitangi in health delivery in Aotearoa New Zealand. Finally, the third contribution provides insight into the need for a transformational shift in the practice paradigm that some professionals appear to work from to embrace this relational way of working in their everyday practice. Unless some professions are challenged on how they define who they are, what they contribute, and what their role is at the most foundational level, then it will be difficult to sustain behavioural change. This issue needs to be addressed at a pre-qualifying training level and reinforced by the regulatory bodies and healthcare organisations into which these health professionals are socialised. RCP or PCC initiatives will not be successful until the long-standing beliefs that these clinicians hold of being ‘the expert’ and ‘in control’, and that their clinical knowledge and hands-on treatment is ‘best’, are addressed.

This study provides significant insights into how the RCP programme can be redeveloped at Te Matua Maui Hawkes Bay (formally HBDHB) to better embed its underpinning principles. A range of implications are discussed including identifying key changes in RCP programme design drawing from the findings, steps that can be taken at an organisational level to enable and embed RCP, and broader implications for allied health curricula and regulatory bodies. The original contributions to knowledge and practice developed through this doctoral research may have significance in influencing and informing the design and implementation of other health delivery programmes underpinned by a similar philosophy in Aotearoa New Zealand and further afield.