Nursing in partnership with the community: forming strong links with the community and advocating for families are the keys to effective public health nursing.

HAMILTON PUBLIC health nurse Anne McNicol was a reluctant starter into nursing. In fact, she says, she did everything she could to avoid it for as long as possible, dreaming instead of becoming a social worker.

Born and raised in Ngaruawahia and the youngest of seven children (she's still known as "Nuki" or "little one" among her extended family), McNicol is fiercely proud of both her Maori and Scottish heritages and the strong matriarchal lines from which she descends. Her tribal links, not only with Tainui, but also with Te Rarawa and Ngati Porou, provide her with invaluable connections throughout the Waikato district, links that greatly enhance her role and effectiveness as a public health nurse in the community.

Although doing her best to avoid becoming a nurse, McNicol did become a nurse aide and trained as a community nurse in Auckland in the late 1960s. In the late '70s, she headed for Australia, continuing on to the United States and Britain, then back to Australia, where she spent the following decade. Working in hospitals in Brisbane opened her eyes to the plight of Aboriginal people and sharpened her awareness of the impact of colonisation on the health and wellbeing of indigenous peoples. "Living overseas also gave me a deep sense of my own identity as a Maori," she said.

It was her father's terminal illness, diagnosed in 1989, that finally brought her back to New Zealand and her Ngaruawahia roots. "I was glad to be home, to be able to care for my lather and to work with our people once again," she said. "After my father's death, I was offered a job as an enrolled nurse with the district nursing team. It was the team who pushed me into doing my nursing diploma, which fortunately I was able to complete over two years hi the first bridging course at Waikato Polytechnic. During this period I became actively involved in setting up Nga Miro Health Centre on our Turangawaewae Marae. The centre now employs 12 people, including two practice nurses, and is a key primary health care service in the community. I still serve as a trustee."

Ten years ago, McNicol accepted a job as a public health nurse with the then Health Waikato. She was one of the first Maori to be appointed and was employed largely because of her understanding of Tikanga Maori and te reo, abilities sorely needed in an area with a high Maori population and disproportionate share of health needs. The team now includes a Cook Island Maori and eight Maori nurses, the largest proportion of Maori public health nurses in any district health board in the country. McNicol also became involved with the local branch of Te Runanga O Aotearoa NZNO, is currently vice chair person of the national komiti and serves on NZNO's board of directors.

McNicol sees her role as working to improve, promote and protect hauora/health and wellbeing of tamariki/children and whanau/families. She is an advocate or "health broker" for at-risk families with a variety of agencies and places enormous value on working in collaboration with mainstream and Maori and Pacific providers, schools and pre-schools, and other community groups. Her role also includes the monitoring and surveillance of communicable diseases, contact tracing and case management of at-risk children.

"In the old days, public health nurses would visit a home and virtually take over. Things are very different nowadays, be cause families are expected to take some responsibility for their own health issues. We are there to support and guide people in the decisions they make, working in partnership with them and protecting their dignity. For example, I don't treat a child's head lice, but will advise families about how best to get rid of the lice and prevent further infestations. I will also work with schools in my designated area on how to develop an anti head lice policy, eg buying treatment shampoo in bulk and selling it to Families at wholesale rates. Other common issues we deal with in schools include developing smokefree policies, coping with eating and hearing problems, referring children to health camps and working on policy development to help protect children from violence and abuse. We don't attempt to deal with abuse cases ourselves but will support school communities needing to report cases to the Children's and Young Persons Service,"

Although most of McNicol's work is with children and families from high decile areas--most referred to her by schools, some by GPs or other agencies--she is also cognisant of health issues facing families from more affluent areas. "In rural areas, I meet fanning families struggling financially to keep their children in schools or children coming home to empty homes because both parents are working. Children living on farms are also prone to accidents with farm equipment. Health problems don't just occur in poorer, city areas."

McNicol is one of three gazetted BCG vaccinators for Hamilton City on the public health team. In this capacity, she encounters numbers of new immigrant and refugee families who not only need their babies immunised and checked for infectious diseases like tuberculosis but are also coping with the stress of adapting to a new culture and environment. "I aim to build a sale and trusting relationship with these families. When I vaccinate a baby I have the opportunity to identify any other health issues the family may be facing like breast feeding and nutrition problems. Recently, I had to refer some Somali children for counselling as it was clear they were still traumatised by their refugee camp experiences. The school they were attending used a siren to signal class times. For these children, a siren meant their camp was under attack."

Working in a culturally safe way is paramount to McNicol. Her upbringing in a traditional Maori environment and experience living abroad in other cultures have contributed to the skills she brings to her work. "I'm a middle-income Maori often working with people from lower income groups. It's important I work sensitively and understand that, for many families, the priority is to get food on the table each day rather than to spend time listening to health messages from me. As Maori nurses, we are also compromised by our own people who may see us as 'brown bureaucrats'. Breaking down these barriers can take time, personal pain and a lot of diplomacy."

When working with individuals or families, McNicol gains her greatest satisfaction from being able to help them resolve a range of health and social issues. She cites the example of providing therapy for a woman who'd contracted tuberculosis. "This required visiting and observing her for six months, ensuring she was taking her medication and accompanying her on her monthly visit to the TB specialist. In order to ensure her safety, I would visit her early in the morning so her neighbours wouldn't notice my arrival. This woman had many social problems as well as her illness to contend with. Because of these multiple issues, she would forget to take her medication and needed someone there to remind her. During the six months I had regular contact with her, she managed to overcome her fear of leaving the house, she found herself a job, got involved in some community, support activities and finally managed to regain the care of her children. It was a wonderful moment when the TB specialist told her he would never need to see her again as all traces of the disease had disappeared. She had thought she would be living with it for the rest of her life. It is so satisfying to see her and her family now living healthy and happy lives."

Immunisation education for other health professionals, including midwifery students, is another aspect of McNicors role. Although immunisation is not mandatory and some health professionals have reservations about possible safety issues, McNicol believes the public has a right to be fully informed about the risks of not having their children immunised.

Preparing children for their immunisations and actually doing the injections can be stressful. During campaigns, the nurses work as a team, ensuring the nurse who normally works with a particular school is not the one who injects the children from that school. "We don't want to be known as the person who inflicted pain on them," McNicol explained. Immunising children in rural areas has its own particular challenge and nurses will ensure they take every precaution possible to avoid complications and adverse reactions in areas with little medical back-up.

The most demanding immunisation campaign McNicol has been involved in was the catch-up in 2001 of children needing the measles, mumps and rhubella vaccine as a measles epidemic threatened to sweep the country. "This was a logistical nightmare. Public health nurses lobbied the Ministry of Health hard for consent forms that could be understood by people who did not have English as their first language. We also targetted at-risk groups who, unfortunately, rarely keep records of what vaccinations their children have had. This required a great deal of patience and professionalism on our parts as we checked and double-checked with doctors that we weren't repeating injections they had already carried out opportunistically. I must have vaccinated hundreds of children during this period. Public health nurses could be facing a similarly demanding campaign once the clincal trials of the anti-meningococcal vaccine are completed and the vaccine becomes available."

During these campaigns, particularly the year seven immunisation for tetanus, diphtheria and polio, McNicol works closely with local iwi health groups like Te Runanga O Kirikiriroa. Te Runanga health promoters and educators Rongo Kirkwood and Sandy Pokaia speak highly of McNicol's strong mandate for iwi groups. "Maori health providers are often left out of the information loop and don't always get an equitable share of resources. Nuki has always kept us informed, treating us with a great deal of respect and valuing our role in the community. By working in partnership, we can help ensure Maori have the same opportunities as non-Maori to access health services."

McNicol may have preferred to be a social worker rather than a nurse, but in her role as an advocate for needy families, she combines both skills. "What gives me satisfaction are the achievements nurses and communities working together can attain," she said.