The changing face of mental health services: the role of head nurse of mental health services in the Waikato region has undergone some major changes over the last eight decades. A former matron and the current clinical nurse director share some impressions.

For over 80 years, mental health services in the Waikato region were centred at Tokanui Hospital, near Te Awamutu. Opened in 1912, the hospital, at its peak, housed over 1000 patients, but by the late 1960s, the government decided no more buildings were to be erected on large psychiatric hospital sites. The building of smaller psychiatric wards attached to general hospitals, and the move to deinstitutionalisation and community care had begun.

Nursing at Tokanui Hospital from 1921 to 1984 was led by the most senior mental health nurse, the matron. Assistant matron roles were also established to support this position. The matron's role was to manage nurses, ensure patients received good care, and undertake a range of other tasks such as ordering supplies, ensuring wards were clean and escorting visitors around the hospital. They also worked closely with the superintendent and/or the senior medical staff. Matrons conducted regular ward rounds to ensure things were in order and traditionally wore a white dress and a short white veil. Many matron positions were held by single women and for lengthy periods of time. It was not until the early 1980s, when the role title changed to principal nurse to reflect the new nursing and management infrastructures, that shorter terms of appointment began and male nurses were appointed to the role. Up until then, male staff held senior roles as head attendants.

The last matron at Tokanui Hospital was Marie Whittaker who took up the role in 1965, retiring almost 20 years later. She was variously known as Mrs Whittaker, Mrs Whir, Ma Whit or, as most people knew her, Matron. After her retirement, she continued to live locally in Kihikihi, and in Te Awamutu after her husband died on one of their trips back to England. She died in December last year at the age of 83. In an obituary published in the Waikoto Times earlier this year, journalist Roy Burke wrote: "She was highly visible in her hospital highly approachable, and the care and wellbeing of her patients were top on her priority list. Although she had retired more than two decodes earlier, a number of former staff and patients paid their respects at her funeral service. They remembered a compassionate and empathetic leader of the nursing team."

Another local resident, Suzette Gisler, holds the current senior nurse position (now titled clinical nurse director mental health and addiction services), based at Waikato Hospital. Whittaker was matron when Gisler started working at Tokanui as a psychiatric assistant in 1980. She began her nurse training two years later. In June last year, she met with Whittaker to share their experiences and discuss the changes in mental health nursing over the decades. This article is based on the interview that took place.

Whittaker and Gisler both started their mental health nursing careers in their late teens and completed a three-year hospital-based mental health nursing training programme. Whittaker qualified in 1946 from the Staff Country Mental Hospital, Bruntwood, in the United Kingdom and Gisler in 1985 from Tokanui Hospital. However, their careers over the next two decades took very different turns.

Whittaker became a ward sister in England until her nursing career saw her immigrate with her husband Albert (also a mental health nurse) in 1958 to work at Tokanui Hospital She admitted they did not like it at first and had difficulty adapting to a "less advanced system." In contrast, within 18 months of qualifying, Gisler left nursing to have more children and in 1990 began working as a mental health nurse at Whakatane Hospital. In 1992 she returned home to work at Tokanui and moved with the service to the new Henry Rongamau Bennett Centre in 1997. Tokanui Hospital is empty now, its site and buildings having reverted to Tainui, the original owners of the land.

Although their early nursing careers took different career pathways, both Whittaker and Gisler arrived at the senior nurse position in their early 40s. Whittaker said she needed lots of persuading to apply, as she was quite happy being a charge nurse. In contrast to Whittaker, Gisler's background was in nursing education and forensic mental health. The step up into the most senior nursing role was a giant leap of faith and a big learning curve.

The interview panels

Both recalled clearly their interviews for the position. For Gisler: "There was an interview panel of six, which included the director of nursing, the general manager and senior doctor for the mental health service, human resource consultant, and a representative from Maori and service consumers. My presentation was titled 'Modern matron' and described how I would fulfill the role if appointed. I gave it my best shot and firmly believe in the saying, "go for gold and settle for silver. "

Around four decades earlier, Whittaker had been interviewed by a panel of two doctors, and faced similar questions. "They delved into how I felt about taking on the position and my reaction to certain things. It was very intense."

Whittaker and Gisler have held the senior nursing position in two very different contexts and eras. In the 1960s, just over 1000 inpatients were cared for by fewer than 200 nursing staff of relatively equal gender mix. Staff all wore uniforms and Tokanui itself was seen as a vibrant community, with its own farm, bakery, laundry and even a sewing room where patients' clothes were made. In 1984, patient numbers were divided into three categories: 249 psychiatric, 418 psychcopaedic and 91 psychogeriatric. The primary focus of the matron's role was on hospital services, as the development of community-based services was only slowly emerging. Regular ward rounds by the matron were a key feature in the daily life of staff at Tokanui Hospital. Nationally, the matrons of New Zealand's eight mental health institutions were isolated from their other mental health nursing colleagues. And locally, they worked at a distance from their senior nursing colleagues in the general hospitals. The role, Whittaker noted, was isolated, lonely and she worked tong hours. Regular meetings with the charge nurses and good working relationships with the medical staff were important. Whittaker's conversations with doctors were largely positive. However, she noted: "We used to have an argument periodically. You know, they used to think this should be done and that should be done and I used to say, "well that's all very nice, that's very nice for you to talk in this manner, but just get cracking out there end bring me a few more nurses.'"

From hospitals to polytechnics

Mental health nurse training at Tokanui Hospital began in the mid 1930s, with the matron playing a huge role in overseeing and teaching. The school of nursing closed shortly after Whittaker retired in the mid 1980s, in response to the move to comprehensive training in polytechnics.

Unlike Whittaker's role, Gisler's position covers a range of services, including the Henry Rongamau Bennett Centre with 108 inpatient beds and an extensive community component, extending from the top of the Coromandel to Taumaranui. In addition, a regional forensic mental health service works with prisons and courts as far away as New Plymouth, Whakatane and Turangi. Although the clinical nurse director role is less prominent locally, it is closely linked to nursing across the local health services and nationally with other mental health nursing leaders. A strong nursing structure comprises clinical nurse leaders, team leaders, nurse educators, clinical nurse specialists, a new graduate co-ordinator and a nurse practitioner. All support the clinical nurse director who works closely with the services managers and clinical directors across the DHB. The emphasis is on working together as a team of health professionals and with the people using the services and their family/whanau. There are around 250 registered nurses and 80 health care assistants, many of whom worked at Tokanui Hospital. Nursing staff wear casual/professional dress and the only evidence of regulation are organisational name tags.

Mental health nurse training remains within comprehensive nursing education programmes. The Waikato Institute of Technology (Wintec) has recognised the need to focus on mental health nursing and offers a mental health stream for student nurses during the second year of their bachelor of nursing programme. Gisler works to support nurses in their first year of practice and provides advice to undergraduate nursing training. There are currently 16 nurses on the 12-month new graduate mental health programme, which includes work within the inpatient unit and in the community. Those who complete the programme will receive a post-graduate certificate in mental health through Auckland University.

Over the decades, the matron and clinical nurse director roles have retained similar features, ie setting best practice standards for quality nursing care, and assisting with the management and recruitment of nurses by providing nursing advice and direction. The central goal of providing the best nursing care for the people who use mental health and addictions services remains unchanged. The senior nursing role requires professional leadership, management skills, and well developed people skills.

However, the senior nursing rote has changed over the decades, just as society has changed. The matrons of yesteryear dedicated a large part of their lives to nursing and were integral parts of their hospital communities. The "matrons" of today are part of a much wider community and exist in a world where a good balance in work and life is needed. Gisler reflects on the isolated matron figure of the past and sees a contrast to her current role and busy life as wife, mother of four, stepmother of three, grandmother of four and masters nursing student: "The demands are great today. However, we must all seek to balance these demands to be effective in our roles as mental health nursing leaders."

At the end of her interview last June, Whittaker shared some words of wisdom with Gisler: "You need to have diplomacy, knowledge and get to know people. It's no use going around with your head stuck up in the air and not knowing the people you are dealing with. You need to stand firm in your position, familiarity doesn't work at all, and it doesn't pay to get too involved in their [staffs] personal matters. You need to be visible and approachable to your staff."

Suzette Gisler, RN, is clinical nurse director of mental health and addictions services at Waikato District Health Board. She is part of a project preparing a history of Tokanui Hospital and local mental health services 1912-2012, to be published in 2012. Email [e-mail] to contribute memorabilia or for further information.