Evaluación cognitiva, funcional y conductual en la evaluación DEMDiAG basal

The second overarching theme was about literature on models of occupational stress, with sub-themes being: workplace demands, individual factors, organisational (health sector) factors, and negative outcomes. In terms of the sub-theme workplace demands, there were five related streams: demands intrinsic to the job, the need for professional development, roles in the (health sector) organisation, relationships at work, and organisational processes and expectations. Regarding demands intrinsic to the job, participants talked about those specifically related to the rural sector[SR04].

[SR04] “Highlight some of the issues related to rural delivery of health services e.g. physical isolation and lots of travel.”

Regarding the need for professional development, participants talked about management skills [SR05], the lack of non-Māori colleagues cultural competence [SR06], and general lack of skills [SR07].

[SR05] “Māori managers don‟t have skills to deal with occupational stress – non-Māori mental health service is far less toxic/has fewer problems or problems are not as frequent as in Māori mental health.”

[SR06] “Non- Māori colleagues lack of cultural competence.”

[SR07] “Some staff, including managers lack of knowledge, skill, ability in some areas (e.g. HR issues like the lack of job descriptions for some staff).”

Regarding roles in the (health and disability sector) organisation, participants talked about the nature of the health and disability sector[SR08], difficult decisions [SR09], leadership issues [SR10], and being the only Māori to have a particular role in a region [SR11].

[SR08] “ED nursing means their workplace relationships are often short-lived and transient.”

[SR09] “Sometimes, when job stress levels [in management positions] are constantly high, a trade off may need to be made between the money that comes with the management position, and salvaging personal sanity.” [SR10] “Some leaders do not want to be accountable with funding.”

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[SR11] “I am the ONLY Māori in this type of role – all others at the same level in other organisations are non-Māori. Therefore, their expectation is that I will deal with „Māori‟ things rather than colleagues taking responsibility and ownership for that themselves i.e. Treaty partners.”

Regarding relationships at work, participants talked about issues with colleagues

[SR12][SR13], and patients‟ whānau members [SR14].

[SR12] “Colleagues can be a source of huge conflict stress – in nursing this is referred to as horizontal violence.”

[SR13] “Ignorance of non-Māori colleagues also an issue – anything „Māori‟ becomes of responsibility of Māori staff to do, even though responsibility rests with the organisation.”

[SR14] “Last night I was verbally and physically assaulted by a patient‟s whānau, because they felt they weren‟t getting enough attention. My primary focus at that time was on meeting the needs of the patient, NOT the whānau – but unfortunately aggression from patients and/or their whānau is not unusual for ED nursing.”

Regarding organisational processes and expectations, participants talked about job descriptions and what is expected of staff [SR15][SR16][SR17], and the requirements of reporting systems [SR18][SR19].

[SR15] “Sometimes, job description requirements are so unrealistic that position holders can‟t achieve what they‟re trained for i.e. people are being set up for failure.”

[SR16] “Constant report deadlines, meetings to attend, risk management responsibilities.”

[SR17] “Nursing position job descriptions require tertiary qualifications as a minimum, and the expectation of a postgraduate qualification (especially in management positions) is high. For Māori this is sometimes

unrealistic.”

[SR18] “Highlight the lack of formalised reporting systems to advise stress/wellbeing issues i.e. currently heavy reliance on personal disclosure about stress issues to governance board.”

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[SR19] “Highlight the outputs versus outcomes measurement of „successful‟ results i.e. no acknowledgement that issues such as parents now smoking outside the house, and parents now using car seats in vehicles, and boil ups now being drained of fat are improvements as a direct result of educational work done by [Māori service] staff. Focus is only on outputs…not outcomes.”

In terms of the sub-theme individual factors, participants talked about Māori cultural issues, particularly expectations of whānau[SR20], and tribalism [SR21].

Participants also mentioned coping strategies, their need to be able to inform management of their issues [SR22], and the need to have their experiences of occupational stress validated [SR23].

[SR20] “Because of my whānau background in health, I have had to fight for recognition in my whānau as a leader in my own right. They have such high expectations of me.”

[SR21] “One issue for this role is tribalism.”

[SR22] “Would be good to tell management „my story‟ and gain some level of healing.”

[SR23] “On a personal level it would be good to have some validation or acknowledgement that occupational stress is happening.”

In terms of the sub-theme organisational factors, participants talked about the culture and climate in the health and disability sector. In particular, participants shared experiences of institutional racism [SR24][SR25][SR26], a lack of recognition [SR27], a lack of workplace social support [SR28], and a lack of appropriate cultural or professional supervision [SR29]. Participants also mentioned how government allocated resources impacted their work [SR30][SR31].

[SR24] “It‟s a struggle to be recognised as a valid and relevant rōpū. Institutionalised racisim is alive and well, and creates barriers to development and progression of Māori.”

[SR25] “Tikanga and Treaty training not prioritised as highly as (for example) fire safety training.”

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[SR26] “I am constantly worried about potential or actual accusations of

financial impropriety just because I am Māori. My non-Māori colleagues are not scrutinised as closely as I am.”

[SR27] “It takes more for Māori to be here [in management positions in the health and disability sector] and often we have to fight to create a sense of worth in our roles.”

[SR28] “Lack of peer support to discuss some of these issues as managers and how to deal with them.”

[SR29] “Need to have clinical and cultural supervision in the same (not separate) person/people as is currently the case.”

[SR30] “Multiple funding sources and therefore multiple accountability (reporting).”

[SR31] “Staffing constraints and therefore huge workload.”

In terms of the sub-theme negative outcomes, participants talked about their own instances of distress[SR32], and how stress for staff led to negative outcomes for the organisation including Māori staff retention and turnover issues [SR33][SR34], and reduced productivity [SR35].

[SR32] “Burnout is a huge issue.”

[SR33] “Major issue – retention of Māori nurses – we need more Nurse Educators in Public Health and in wards – to provide quality service through quality staff.”

[SR34] “High staff turnover.”

[SR35] “Lots of personal grievances, many cases of „stress leave‟, organisation well known with HR for breaches of OSH.”