A passion to promote nursing and prevent illness: for 40 years, Noeline Warmington has devoted herself to promoting nursing and raising awareness of Maori health. She hopes she has been useful to somebody.

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Northland nurse Noeline Warmington has lived and worked around Kaitaia, the Hokianga and the Bay of Islands all her life. Over the last 40 years, her passion to promote health and prevent illness, particularly among Maori, has continued to deepen.

When Warmington decided to train as a community nurse in 1966 through Kaitaia Hospital--she was in the first class of the new two-year community nursing programme--it was really because she was unable to train as a veterinary surgeon. Back in the '60s, that wasn't considered a suitable career for women and it would have meant going to Australia to train. She discovered that nursing was the next best thing to becoming a vet.

"My family were farmers, so my whole life had been about milking cows and feeding calves and pigs," said Warmington. "Nursing seemed to be all about sick people, which did not appeal to me very much. However, by becoming a community nurse, I thought I would be out in the community helping to stop people getting sick in the first place. That seemed much better to me than working in a hospital."

However, it was to be another three decades before Warmington, who is of Nga Puhi descent with sub tribes Ngati Kahu and Te Rarawa, really fulfilled her wish to work in the community. When the community nurse programme disappeared, she was transferred onto the enrolled nurse (EN) roll and spent the next three decades working in hospitals in Kaitaia, Rawene and the Bay of Islands. She married local farmer/ freezing worker Thomas Warmington in 1969 and helped support her growing family by doing night shift work. "My family has always kept me grounded," she said. "Those early years raising a family were pretty tough for us financially. My nursing work really helped keep the family finances going."

In the early 1990s, Warmington completed her diploma of comprehensive nursing through Northland Polytechnic, followed by her bachelor of nursing a few years later. "During my first year of the two-year bridging programme, I was a terrible student because I thought I knew everything about nursing. I was very defiant. But by the second year, I began to understand what nursing was really about and became hungry for new knowledge, particularly about how the body really worked.

"I realised that as an EN, I had been very task-orientated. My priorities had been on running a tight ship, on keeping everything shipshape and tidy. I will always be grateful to Northland Polytechnic for that bridging programme, for the awesome tutors we had and the great clinical foundation they gave us. Being an EN had been a great start to my nursing career, but doing that bridging course helped me understand where I needed to go."

Warmington's first real primary health care experience was her clinical placement with Plunket during those two years. This led to a strong commitment to the Plunket movement, to three years working as a Plunket nurse in Kaikohe and surrounding rural areas (the poorest region in Northland), and seven years as the national Maori clinical educator. "Working for Plunket taught me so much, particularly about how it takes a community to make a family. I also felt very comfortable with the Maslow hierarchy of needs and model of human development, as this is also a Maori model and fits well with health models like Te Whare Tapa Wha.

"Being able to work with families in their homes is such an honour. As a Plunket nurse, I travelled huge distances and did a lot of listening, as people shared with me their worries and fears. I would then encourage and affirm them in the decisions they made for themselves and their families. They may not have had a lot materially, but they all wanted to do the best they could for their children."

When Warmington became a Plunket nurse in 1995, only 38 percent of local families with new born babies used the service. At the end of her three years, 98 percent of babies born in the area were being cared for by Plunket. When iwi providers were established, Warmington worked closely with them, supporting them as they delivered the Well Child contract in ways that were cultural appropriate for them.

Educating Maori nurses

However, her most satisfying role with Plunket was the seven years she spent as a clinical educator, delivering the 40-week post-graduate diploma in community, child and family health to between 15 and 20 Maori students a year, scattered throughout New Zealand. "Six or seven years ago, there were about 240 iwi providers and I worked with about 90 percent of those that delivered the Well Child contract. I also worked with Maori nurses working for Plunket who preferred to be taught by the Maori educator. Every single nurse who provides the Well Child service has the same prepartion to be at the same level and, at the moment, must complete the Plunket post-graduate diploma course. It's a really great system."

Warmington notes there are now three Maori nurses doing the educator role she did on her own. She is also concerned that Plunket and other non-government organisations may have difficulty accessing the Clinical Training Agency funding for post-graduate studies. This funding is now being directed through the district health boards to directors of nursing who will make the decisions as to how this will be spent. "Nurses working in the community, and particularly in rural areas, need post-graduate education and the opportunity to increase their skills. They are often working on their own and do not have the same clinical support that nurses in hospitals have. There is so much health prevention work to do in the community and you need highly skilled nurses to pick up on the range of health problems they encounter. If my mokopuna are sick, I would like to know they will be seen by a highly skilled and educated nurse."

Warmington knows first-hand the difficulties rural people face accessing the health care they need. If she lived closer to the city, she knows she would get more immediate care, and there would not be the same difficulties attending appointments and getting the medication she needs for her cancer.

Multiple roles with NZNA/NZNO

For as long as she has been nursing, Warmington has been a member of NZNA/NZNO. Always a campaigner for fairness and justice, she believes her involvement with NZNA/NZNO gave her a much deeper understanding of the challenges and issues facing nurses across the country. She served as chair of the national enrolled nurses' section in the 1980s, was chair of Te Runanga o Aotearoa from 1999 to 2001, and was vice-president of NZNA and NZNO, serving for two terms. She was the first Maori nurse to be elected to the then NZNA national executive, representing Te Tai Tokerau, and in 2001, became the first Maori to stand as NZNO president. Although she was unsuccessful, she believes putting herself forward helped raise the profile of Maori within the organisation. She has also served on the Nursing Education and Research Foundation.

At the 2001 NZNO conference, Warmington introduced a remit proposing that Te Runanga have two representatives on the board of directors. Having only one Maori representative--the Te Runanga chair--was a lonely position, she said, as there was no one to support and awhi the chair when s/he offered a Maori perspective on issues being discussed. Having two representatives would also demonstrate NZNO's commitment to the Treaty of Waitangi. The remit was passed.

During her term as Te Runanga chair, Warmington believes much greater recognition for the place of Maori within the organisation was achieved. She is proud of the Memorandum of Understanding that was signed between Te Runanga and NZNO during her tenure--this helped move NZNO along its journey towards partnership. "Until that time, there was really nothing in writing about our kaupapa. Having a memorandum meant we all got into the same waka, although on occasions we paddled in opposite directions," she said.

Warmington is delighted to see the growing sense of partnership between Te Runanga and NZNO, and respect for treaty obligations. "Te Runanga and NZNO are now very closely linked. I am glad I was able to provide leadership during part of this journey."

Serving on Nursing Council

Warmington's membership of the Nursing Council has been hugely important to her. Appointed in April 2002, she has served two three-year terms, bur will not seek a further term due to her ongoing health problems. When she was first appointed, she was one of three Maori members, but is finishing her second term as the only one. The last term has been rather lonely for her. For several years, she and NZNO fought for a permanent Maori seat on the Council. However, Warmington no longer supports this stance, believing that members must primarily be there to represent nursing, rather than a particular ethnicity or face. "However, we need more Maori nurses on Council. That means more Maori nurses need to be nominated. As Maori nurses, we don't promote ourselves well enough. We could nominate Maori to fill the lay person's position on Council, for example."

Warmington hopes a Maori nurse will be appointed to fill her shoes, along with other Maori members. Looking back, she says her involvement with the Council's former disciplinary committee and the current health committee have been particularly satisfying. She admires the work the Council does to help nurses who have physical, mental or addiction problems continue nursing, putting monitoring and some practice conditions in place to protect both them and the public. "Most nurses understand the purpose of these conditions, though a few find them threatening."

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Warmington believes her broad knowledge of nursing and strong clinical base have contributed to her effectiveness on Council "When Council makes a decision affecting nurses' regulation or education, I immediately put myself in the nurses' shoes to assess how any changes will affect their practice. This, I believe, has been the best contribution I could make." Although Warmington's own iwi is important to her, she has lived primarily with her husband's iwi, Te Ma Hurehure, based in the Hokianga. However, even more important to her than knowing where she comes from and who stands behind her is the contribution she has been able to make during her nursing career. "I have had a wonderful journey as a nurse and I would like to think I was successful, that I did something for nursing and for Maori. My involvement with NZNO and the Nursing Council has given me great opportunities to continue promoting nursing as a career and raising awareness of Maori health issues. I hope I have been useful to somebody."

Warmington believes Maori must learn to work together better across tribal boundaries in order to make a real difference to Maori health. "Although working within separate iwi has its strength, we need to be able to think more broadly as a people. We need more Maori health professionals working among their own people and we must do a lot more to encourage young Maori to go into nursing. Maori providers could perhaps sponsor a young person and then bond them to work for the provider at the end of their studies. We must think creatively if we are going to increase the proportion of Maori working in health. Iwi providers have made a huge difference to Maori health, eg reducing the numbers of children being admitted to hospital for respiratory diseases, but we need more of them and they need to be better resourced."

Over the last two years, Warmington has worked four days a week at the Northern Correctional Facility at Ngawha. She has found the work intensely interesting and a good extension to her primary health care skills. Having mental health skills, including an awareness of the effects of medication used in mental health treatment, would be an advantage for nurses working with inmates, she says. "Many inmates are remanded for the sake of peace in the community while they await their court case. A number should really be admitted to a mental health facility, rather than being arrested. This has been quite an eye-opener to me."

Warmington has recently resigned from her prison work, a very difficult and painful decision for her. "I really miss my colleagues and wish I was back there now. I keep dreaming I will be able to go back to work, but I don't know that I will be able to. We can't choose what's waiting for us around the corner."

While not knowing what the future may hold, Warmington takes comfort in having her extended family of three sons and nine grandchildren living close to her in Northland. They are another legacy of which she is justifiably proud.

By co-editor Anne Manchester