Taking a nursing service into the Bush: an occupational health nursing practice in Nelson gives new meaning to the term "accessible services'.

The rain Lashes down. Steam belches over the sawmill yard. Dawn Lights up the pine-dad ridges. Log-Laden trucks pull over the weighbridge and the drivers run to the smoko room, with its battered chairs and tables, bags strewn over the floor, broken coffee dispenser, dirty mugs and fluorescent Lights. Laminated pages outlining safety procedures are stuck to the walls. This is, undoubtedly, masculine territory.

Pot-holed forestry roads ziz-zag up a mountain, the rugged clay and rock-scarred hillsides the site of a silviculture gang's planting work. Members of the gang trudge towards the contractor's van, their wet weather gear soaking, their shovels dragging at their sides.

A pool room--another masculine domain--features a full-size billiards table, a Large screen, tiered seating and a bar. French doors open onto a swimming pool and garden.

These settings are all in a day's work for occupational health nurse Peter Bird. Based in Nelson, he has specialised in providing services to some of the big players in the region's significant forestry industry. He has come a Long way in the seven years since he established his practice. Back then, he began with an audiometer, a Log haulage company his only client, his nursing experience and his vision for an occupational nursing service that would serve the forestry industry when and where needed. Bird was a Late starter in nursing. He graduated in 1997 after twece years' labouring, time as an alcohol and drug counsellor, working in a treatment centre for recovering alcoholics and addicts, and as a Lifeguard. He realised that if he wanted a satisfying career that would support his family, he needed qualifications. He chose nursing. His mother and sister had been nurses and he had enjoyed working with students on clinical placements in the treatment centre. Being a nursing student with three preschoolers was tough on the family, but he's glad he persevered. He first worked as a casual nurse at Nelson Hospital and then moved to Ngawhatu, a Large psychiatric hospital, as deinstitutionalisation was in full swing. He was involved in intensive rehabilitation of those deemed unsafe to Live in the community. "I Loved the work. The team I worked with was fantastic and some of those people who were thought to be too dangerous to Live in the community are now Living safely in community homes. But I found the health system very difficult to work in. It seemed to be full of egos and any creative or innovative ideas were crushed."

He began his occupational health business in response to demand. His wife Robyn had established a first-aid training business, Precious People and, when providing first-aid training to companies, she was often asked if she could do hearing testing or health monitoring. So Bird decided to test the waters. Purchasing a $3000 audiometer and undertaking a two-day audiometry course proved the Launching pad for his practice. As the business grew, he continued working afternoons on a three-on, three-off roster in mental health, devoting all his spare time to the burgeoning practice. The practice was demand driven--industries wanting hearing testing often also wanted alcohol and drug testing and health monitoring. "I Learnt as I went, augmenting my nursing knowledge with information gleaned from experts in the various fields, who were always happy to share their knowledge, and from the internet."

But burnout Loomed. "I'd already burnt out when working in the addiction field and I didn't want to go through that again, so I decided to move into the business full-time."

Bird had seen the opportunities in the forestry industry and decided to pursue them more vigorously once working in his practice full-time. "I Love the people. I'm from a farm and I Like practical, down-to-earth people. Most of them are as straight as the trees they grow."

But his vision of an accessible occupational nursing service meant big investment--in a four-wheel drive vehicle for forestry roads, in equipment, in a mobile office, including a radio telephone and fleetlinke, a bush phone, for when he was working in the forest plantations. "There was no education about being a nurse in business when I was at polytechnic. The training was still, in my mind, very much geared towards nurses working in hospitals." But he and his wife decided to take the bull by the horns and make the necessary investment. The returns in terms of business growth have justified their decision.

Drug and alcohol testing

Drug and alcohol testing of all forestry workers working for firms contracted to Weyerhaeuser New Zealand, and annual health assessments for a range of forestry contractors are the bread and butter of Bird's practice. Weyerhaeuser New Zealand is a forestry company which manages 65,000 hectares of Radiata and Douglas fir plantation forests in Nelson and Marlborough. Its new drug and alcohol policy, which Bird helped develop, states that every year one third of its contractors' workforce must be randomly tested for drugs and alcohol. Bird manages the whole process from the random selection, the collection of urine specimens, the dispatch of the specimens to ESR, and responding to positive samples. He is a certified ESR collector, a certification that must be renewed annually. Alcohol testing is by a breath alcohol tester.

Any worker with a positive test is immediately stood down and referred to the Nelson Alcohol and Drug Service, where they are assessed as either a Low- or high-risk user. Bird has developed a memorandum of understanding with the service which ensures that workers are seen and assessed as soon as possible. Workers who have tested positive are placed on a six-month rehabilitation contract. Another positive random test in that time means they Lose their job. Bird has no qualms about this work. "Forestry work can be unforgiving if you make a mistake. There have been two fatalities in the time I've been working in the industry. There's sharp, fast-moving equipment, falling trees, steep country, big machines and nobody wants to work with somebody who might be impaired because of alcohol and/or drug use. And referral to the service might change somebody's alcohol and/or drug use."

When he first began random testing, Bird was met by hostility from some contractors and their workers. "It was something new and some saw it as a threat. But once I explained the reasons for it and provided education about the test and about a range of drugs, most people were happy to co-operate."

Collecting a random urine sample from a worker out in the bush or in driving rain on an exposed mountainside poses certain challenges. "You need more than a bedside manner up here," Bird says, after explaining the test, randomly selecting two members of a tree planting gang--their names pulled out of a hard hat--doing the paperwork, getting the sample and ensuring it does not get contaminated, all in cold, driving rain. But the workers seem unperturbed. "Despite the adverse conditions, I still have to maintain people's dignity and give them some sense of control. The communication skills I developed through my alcohol and drug work and in mental health are very, very useful."

Once the samples have been collected and secured, and Bird, huddled into the contractor's van, has given the gang some brief drug education, it's back down the mountain, along forestry roads and a 40-kilometre drive back to the main highway. "One of the great advantages of this job is that I get to go places I wouldn't have access to otherwise. I see some beautiful country."

Once back in Nelson, the urine specimens are couriered to Wellington, with results back within 24 hours, except for positive tests which must undergo further screening. Positive drug tests are relatively uncommon and the number has dropped since the alcohol and drug policy was introduced.

Health monitoring

Health monitoring out in the bush is conducted in Bird's roomy four-wheel drive vehicle. But on the day Kai Taild Nursing New Zealand is shadowing Bird, health monitoring is carried out in the Luxury of the pool room, part of a Large log haulage company's complex. Five truck drivers are due for their annual health check. The annual assessment involves checking the ear canals, a hearing test, blood glucose and cholesterol tests, blood pressure and a vision test. While testing each of the drivers, Bird keeps up a steady flow of banter. This company was the first he began working with, so he knows these men well. One proudly tells Bird he took his advice Last year about "Losing a bit of weight and doing a it of exercise" after a series of high BP readings. The driver's work on the treadmill he bought has paid off in the loss of 10 kilograms and a normal BP reading. Both are delighted.

Change takes time

"My work has a different time frame from a hospital ward. Sometimes I'm the only health professional these men see from one year to the next, so I take the job seriously. The rewards are when someone does take my advice and makes some positive health changes. I see myself as a change agent but I know that change sometimes takes a long time."

While much of his work involves nursing tasks, he says the tasks are "almost incidental to the time spent with people". It is the relationship aspect of his work he finds most satisfying. "I have to build a lot of relationships--with company managers, with contractors, with workers, with other health professionals, with other health providers. I don't have all the answers so I'm very happy to refer people on. Working independently rather than in a team means work satisfaction is very much based on my skills and how I use them in building relationships of trust and helping people make changes." Bird offers an employee assistance programme as part of his service, referring those needing help to a qualified counselor.

Professionally, he is part of a local group of occupational health nurses. The group meets monthly and often has a speaker. "Because most of us work autonomously, it is important to get together for professional support."

Bird abandoned a diploma in occupational health through Otago University as it was not relevant to his practice. "Education sessions on subjects related to my practice, eg asthma and infection control or a spirometry course, are far more worthwhile from my point of view."

Bird is particularly proud of the anaphylactic shock training course he has developed for bushmen exposed to bee and wasp stings and hours from medical help. It is a three-hour course covering the signs and symptoms of anaphylactic shock and its treatment, including administering 0.5ml of adrenaline via a subcutaneous injection. A local GP checked the course content. Bird, in conjunction with a local pharmacy, supplies forestry gangs with "ana kits". The course has already saved a life. Two men who had done the course and had the kit went to the assistance of a man who had been stung while working with a crew 20 minutes' drive away along forestry roads. The medics, who arrived Later by helicopter, said without the adrenaline the man would have died. "It's pretty satisfying to know the course I developed and deliver helped save that man's life," Bird said.

Business skills, systems and processes have been Learnt on the job, by trial and error and with assistance from independent nursing pioneer Annette Milligan.

Bird is always thinking of new services to offer and is contemplating the future. "The business is almost at the point where we could employ another nurse but I'm not yet sure I want to go down that path." But what is sure is that he wants to continue expanding his practice within the forestry industry--"they're my kind of people and I love working with them".