Finding better ways of raising awareness of diabetes: Despite the high incidence of diabetes among Maori people, diabetes nurse clinician Maitera Tutahi is not disheartened. Patients just need lime to overcome their fear of the disease and the confidence to make changes.

Diabetes nurse clinician Maitera Tutahi never set out to work exclusively in diabetes, but "when you see your own people not doing too well in the community, you redirect your focus. That's how I have come to be working exclusively in this area. It's my passion now."

Tutahi, who is of Ngati Toa descent, saw her first diabetic patient in 1998 when she began working for the Maori health provider Hora Te Pai in Waikanae after completing her nursing degree through Whitireia Community Polytechnic. Even at the time, she thought she could have managed that patient better if she had had the right training.

"During the two years I worked for Hora Te Pai I was the only nurse delivering the Whanau ora contract. A high proportion of the patients I saw had diabetes and I was still learning about the disease.

"When I joined Ora Toa Health at Porirua's Takapuwahia Marae two years later, I enrolled in the disease state management (DSM) postgraduate course for Maori nurses delivered through Auckland University. Being able to study with 38 other Maori nurses and to have their support and encouragement was really stimulating. My knowledge of diabetes, heart disease and respiratory disease was increasing all the time, but my pathway gradually unfolded before me, with my focus increasingly on diabetes."

Three years ago, Tutahi was approached by Capital and Coast District Health Board (CCDHB) to join its small diabetes team, based at Wellington Hospital. At the end of 2003, she moved her base to Keneperu Hospital where she now works as a diabetes nurse clinician, the only Maori nurse in the CCDHB diabetes team. In this capacity she sees patients across the board, though around 60 percent are Maori. She works closely with Samoan diabetes nurse clinician Ula Fatialofa who is largely responsible for seeing Pacific Island patients. Both nurses work closely with the doctors, consultants and registrars in the endocrine department, and also with community nurses and doctors in the local primary health organisation (PHO) Ora Toa Health.

"I feel I am in the right position to make changes in patients' understanding of their disease and how best to manage their symptoms," said Tutahi. "Working at Keneperu is great because of its strong community focus. It's a non-threatening environment and I do my best to keep it that way by greeting patients in the waiting room in a marae style, then bringing them myself into my office for their consultation. I do a lot of listening, hearing about all their needs before I start teaching them about their diabetes.

"So many patients still lack a good understanding about the disease and how best to manage it. If they are feeling well, many won't take their medication. I want to help people keep well by encouraging them to use their blood glucose meters and understand why that is important. I try to reinforce these skills regularly and in a non-threatening way."

As well as running her own hospital clinics, Tutahi works closely with the hospital podiatrist and dietitian and intends making stronger links with sexual health specialists to assist men needing help with sexual functioning. She will make house visits when required and maintains strong links with other health professionals working within the hospital and within the community, during a weekly diabetes journal club. "Each member of the club takes it in turn to research and present an article to the group, with discussion leading to good learning for all. This is a great way to strengthen our relationship with those working in primary health care," she said.

Many of the patients Tutahi sees are very fearful of the disease and unwilling to admit they have it. They may have had a grandparent with diabetes who died of renal failure or had a lower limb amputation, so they believe there is little they can do to stop the disease's progression. Changing fixed attitudes can be hard.

"Some people who I refer to the dietitian won't turn up to their appointment as they believe the way they offer hospitality through food will be questioned and they don't want their traditions challenged in this way. There certainly is a link between Jack of exercise and obesity and some traditional Maori customs, but changes are starting and many marae now offer healthier food than they did in previous years. We need a joint effort to ensure those sort of changes keep happening.

Tutahi believes her own marae upbringing in Plimmerton gave her many advantages, including learning to relate well to others and being aware of the importance of maintaining a healthy lifestyle.

"I remember when I grew up at Hongoeka Bay Marae in Plimmerton that we always enjoyed our pork and puha boil ups, but I don't remember eating junk food. We worked as a community to collect and prepare our food, particularly kai moana. There have been a lot of changes at our marae in recent years. We still have our bolt-ups but we take the fat off the meat first. And cakes are only offered if people particularly request them.

"We were a very sporty family. We hardly ever watched TV and we would walk from Plimmerton to Porirua to visit our friends. We would spend whole weekends camping on the beach, swimming, gathering kai moana or exploring the bush. Everyone went because it was fun doing things together. We were also very aware of health issues as quite a number of our extended family were involved in health. Dr Maui Pomare, who was the first Maori medical officer of health in the Department of Health in the early 1900s, is related to me on my mother's side." Tutahi is also proud of her schooling at Hukarere Maori Girls' College in Napier and her final years at Mana College.

Understanding why some Maori do not exercise as much as they should is a complicated issue, she says. Many of the reasons, she believes, are to do with their low socio-economic status which towers their motivation to get out and do things to improve their health. "I tell people they need to make changes for themselves, not to please me or any other health professional. I also link people to services that will help them overcome some of the challenges of their daily lives, eg the PHO will pay insulin costs for certain people and provide people who have difficulties getting to medical appointments with taxi chits. Some patients feel trapped and don't know how to find the help they need. They lose motivation, don't eat well, give up taking their insulin and having contact with other people. They begin to regard themselves as hopeless cases and then often get labelled as 'non-compliant'.

"The only way to reach these people is to listen to them and give them time. Fifteen minute appointment slots just do not work. My role is to listen and then suggest services that might need their needs. A primary health nurse is then more able to give them the extra time they need."

Tutahi avoids using the term "non-compliant" altogether, as she finds it a judgemental term that does little to boost people's morale and self esteem. In her experience, there is no single right way of reaching people. Waiting for people to be ready to make changes for themselves is the only method that works. This requires time and patience.

One of her recent success stories concerns a woman with diabetes and cardiac problems who had been house bound for six years. What this woman really missed was being able to go to her marae. Despite some health professionals believing there was little that could be done for her, Tutahi arranged for her to receive a mobility scooter. As a result, she is now rarely at home, takes her medication and is looking after herself. "She never liked testing her blood sugar levels but now she knows when she should do it and why. She is also being much more careful about her diet. She shares what she knows and even teaches other people with mobility scooters how to manage them. She will ring the GP occasionally to get her prescription repeats and the community nurse will ring from time to lime to check all is well Overall her use of health services is much less than it once was. She is one of my success stories."

Tutahi believes the way health services, particularly hospital services, measure patient successes is limited. "Currently our only measure is through the number of referrals and discharges we make each month. But that is very limited. For me the quality of those referrals is far more significant than just the numbers." Tutahi finds being the only Maori nurse clinician working in diabetes at CCDHB a lonely position at times, and she and Fatiolofa continue to advocate strongly for increased funding to enable more Maori and Pacific Island nurses to be employed, both for the welfare of the patients and for their own professional wellbeing and satisfaction. "We can talk to out colleagues about our cultures but there is not the same rapport as when you can share these things with your own people. I miss the professional support of other Maori nurses that I had when I was a DSM nurse. It was great being able to share problems with someone who really understands where you are coming from. But my passion for improving the health status of Maori people keeps me going, along with the realisation I couldn't do what I am doing outside the specialist clinical field." There are no quick or easy answers to reducing diabetes rates among the Maori population, Tutahi says, and she supports the need to maintain a balance of Maori nurses working within "mainstream" health services and for Maori providers. The more complicated cases will always need to be referred to hospital services. "For me it is important to be able to keep good, strong relationships with the two main Maori providers in this area. The number of providers hasn't changed over the last few years, but the services they offer are growing and expanding, which is good."

In the long term, Tutahi sees herself nursing back in the community, particularly once she achieves her next goal of becoming a nurse practitioner (NP). "There are a lot of people who believe that is what I should aim for and where I should eventually be. They are encouraging me to continue increasing my skills in diabetes, so becoming an NP, perhaps eventually with prescribing rights, is my logical next step."

Tutahi is now studying for her first stage examinations towards achieving NP status and hopes to do a master's paper in diabetes through Waikato University next year. She remains positive that she and others like her can make a real difference to the rates of diabetes among Maori people, rates that are up to three times higher than among non-Maori. "All is not lost; it's all about finding better ways of reaching people to raise their awareness of the disease and what they can do to prevent it or manage its symptoms," she said.