The delights and dilemmas of rural nursing: nursing in isolated rural communities poses practical, personal and professional challenges.
South Westland is rugged country--farms hewn from bush, dangerous alpine environments, capricious weather and relative isolation--the bridge over Haast Pass was opened in the early '60s. The communities that have grown up in this part of the country reflect some aspects of their environment--resilient, wary of newcomers, caring, tough and enduring--some family names indicate generations-long settlement. It takes a special kind of person to nurse in that physical and social milieu.
Anne Fitzwater, a nurse practitioner (NP) based at Fox Glacier, is such a person. A self proclaimed "smart town rural person", she has been working at Fox Glacier for the Last six years. In that time she has gained her clinical masters, been endorsed as an NP in rural primary health care (PHC) and, at the beginning of this year, she gained prescribing rights.
The community, in the shadow of Aoraki Mount Cook and 200-odd kilometres from the nearest hospital, has around 400 permanent residents, with another 200 employed as workers in the hospitality industry from September to April Hordes of tourists descend on the region annually--Fox Glacier has 1500 tourist beds, most of which are full every night during the season. And this disparate community has grown on Fitzwater, who, when she arrived, was determined to stay "two years max". So what's kept her so long?
"West Coasters are unique. They've lived in isolation in relatively recent times. There's a tong tradition of hospitality and it's a very caring community."
Fitzwater knows her rural communities. She hails from Waikouaiti north of Dunedin, has lived in Northland, did her nursing training at Masterton Hospital, beginning in 1980, and worked there for a total often years, was nurse manager at the 12-bed Roxburgh Hospital, was nursing co-ordinator at Dunstan Hospital in Clyde and returned to hands-on clinical work at Ranfurly Hospital. From 2000 to 2003, she was self employed, contracting herself to different general practices in Central Otago, including Glenorchy at the head of Lake Wakatipu, providing cover for GPs at weekends and also relieving rural nurses when they were on holiday. While doing this, Fitzwater completed her diploma of primary rural health care, developed by rural nurse researcher Jean Ross and delivered through Otago University.
"That course provided us with exactly what we needed to know to do our work safety," she said. She also believes her experience at Masterton Hospital, particularly in its emergency department, was very sound grounding for her work in isolated rural communities.
Living in Alexandra, she went to Fox Glacier for two weeks, as a relief nurse, not thinking she would like the Coast. She returned to Central Otago and found herself wondering how "so and so" was--"the community had realty got to me." To such an extent that when the permanent nurse, Louise Davidson left, Fitzwater took on the rote.
Her patch ranges go kms south to Paringa and north to Franz Joseph, extending to far Okarito when she provides cover for the nurses (two part-time nurses fill the role) at Franz Joseph on their days off. She has one of the eight full-time rural nurse specialist (RNS) positions covering the Coast from Haast to Karamea. The RNS are based at Haast, Fox Glacier, Franz Joseph Glacier, Whataroa, Hari Hari, Moana, Ngakawau and Karamea.
Fitzwater works ten days on, including being on call 24/7, and four days off. In her time at Fox, there has not been a ten-day period when she has not received an out-of-hours call.
The position has provided her with challenges aplenty and continuing job satisfaction. Her rote is pure PHC in its many guises: ante- and post-natal care, in consultation with midwives based in Greymouth and the GP based 60 kms north in Whataroa; Well Child care, immunisations, school visits, district nursing, public health, sexual health, clinics every morning in the purpose-built health clinic, education, health promotion, elderly care--"tho' there's not much of that, as those who stay here are pretty tough"--and art manner of accidents and emergencies, often reflecting the nature of the environment. In the week before Kai Tiaki Nursing New Zealand's visit, Fitzwater had been involved in two accidents on the glaciers.
In one, a man had fallen while climbing on Franz Joseph Glacier. The GP flew onto the glacier--"we try not to call him out at weekends but he sometimes volunteers in an emergency", she said. If he had not done so, Fitzwater would have been the first health professional on the scene. She and all the other RNS are PRIME (primary response in medical emergencies) trained.
The other accident involved a man pinned at his abdomen under a massive boulder. The paramedic went onto the glacier and inserted the IV line. Once the boulder was lifted--by Fire Brigade machinery flown in by helicopter--the man was flown to Fox Glacier, stripped of his wet clothing, stabilised at the clinic and then flown on to Grey Base Hospital.
She says that when a helicopter is needed, it's the local pilots you want flying them. "These guy were all involved in venison recovery and they know their mountains."
It is a three-hour drive to Grey Base Hospital and a minimum of an hour by helicopter.
A volunteer ambulance group operates in Haast, Fox, Franz and Hari Hari. Two volunteers in Fox are advanced paramedics who provide wonderful back-up for Fitzwater. "When something major goes wrong, they try and make themselves available but they are a couple with a baby and are managing a motel."
The night before she had been at work unlit 9pm, accompanying an elderly man, who needed intravenous pain relief, in the ambulance to Whataroa, where an ambulance from Grey Base Hospital took him through to Greymouth.
While mountain, farm and traffic accidents make up most of the emergency work Fitzwater is faced with, PHC is the "bread and butter" of her practice. Within that, given the age and transient nature of the population working in hospitality and tourism in the area, sexual health is a significant component of her work. Family Planning Association courses plugged some knowledge gaps and it is in this area that the benefits of her ability to prescribe have been very noticeable.
"A young woman working in hospitality enrols at the clinic. I don't have to refer her on to the GP for any sexual health issues or contraception. It is within my scope to manage a sexual health check, treat according to the results and advise her on her contraceptive pill. That is very satisfying. Previously she would have had to wait for the next GP clinic (held one afternoon a week at the clinic) to discuss changing her contraception but I am able to do all that in one visit."
Fitzwater says that her NP. endorsement in the rural PHC scope has given her greater confidence in her rote. "Advanced health assessments, diagnostic reasoning, pharmacology and specialist prescribing are almost essential in this environment. I felt I was constantly in situations where I was pushing the boundaries of the registered nurse scope of practice. In all sorts of situations, I was having to make diagnostic decisions. That was the push for me to become an NP. Prescribing has been the icing on the cake," she said.
The West Coast DHB supported Fitzwater financially, with study leave and through the NP application process. But now she is an NP and her scope of practice is recognised, eg she can order diagnostic tests in her own name, she is not being paid at the NP rate under the national multi-employer collective agreement and that is frustrating.
"All the RNS positions in South Westland, with the amount of autonomy and accountability required, should be NP rotes. The job descriptions for the rote state that we assess, diagnose and treat. We are working at a high level of practice. The Nursing Council is looking at colposcopists and surgical first assistants. Welt, our rotes are far more autonomous and I'll be making submissions to the Nursing Council on this. We are working from standing orders but if you are working from an asthma standing order, you have to know the patient has asthma, rather than any one of a range of other respiratory problems."
While she works atone, she does not work in isolation. "I have a close working relationship with the other nurses. We all support each other." The GP is also a source of support. Working and Living in such a small community poses certain difficulties. "You are very close to your community. When someone dies, for example, it is like losing one of your friends. You have to deal with your own and others' grief."
Maintaining confidentiality means "I don't say anything about anybody and that can be difficult".
And it means a cup/of coffee in a cafe away from the main street, is interrupted by people asking questions about the man transferred to hospital the previous night--"the bush telegraph is a far more effective and faster way of communicating than any electronic communication"--or telling Fitzwater about a health issue or asking when tab results might be back. All such public queries are handled with utmost discretion. While such a "fish-bowl" existence has its downsides, Fitzwater knows those same people will help that man on his return to the community, provide firewood for a family in need, or clean the house and Leave a casserole for a new mum and baby returning from Greymouth. "What happened all over New Zealand 30 years ago is stilt happening here."
Fitzwater's stand-out memories from her time in Fox Glacier include high drama and the more mundane but equally memorable occasions in the life of the community. She remembers a helicopter flight with a paramedic to a hunter injured on a notorious alpine ridge in difficult weather. "As we approached, we saw the debris of the last helicopter to fly in that area. We were very quiet as we landed."
Or there was the horrific accident when a local boy was run over twice on State Highway 6 and kilted. On another occasion a member of a family that had Lived in the area for generations was beaten up in the middle of the night and Fitzwater attended him. "I knew that family respected me more after that because I'd been there for them."
Happier memories include visits to an elderly man who lived atone in a hut up Jacob's River. "It was quite a trek up to see him but it was always an absolute delight to spend time with him. He had a great deal of wisdom." He died suddenly earlier this year, while Fitzwater was on holiday, but she made it back for his funeral
Then there was the couple celebrating their 50th wedding anniversary, renewing their vows as part of the festivities. "Afterwards, as T was congratulating them, the woman said: 'if it wasn't for you, I wouldn't be here.'"
A couple cared for their dying baby for three months. "When the baby died, they said to me: 'We hope you know we couldn't have done this without you: Those are wonderful memories and I feel so privileged to be part people's lives in that way."
But after six years of relentless on-call work and the intensity of nursing and living in a small community, Fitzwater thinks she is close to her "use-by date" like so many rural practitioners, she is also dose to retirement age.
She treasures the rewards of rural community nursing and acknowledges all nurses, in different ways, have similar experiences. "That's why we all go nursing, but it is a far closer relationship in an isolated rural community such as this," Fitzwater said.
And that is both the delight and the dilemma facing all rural nurse specialists.
By co-editor Teresa O'Connor
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|Publication:||Kai Tiaki: Nursing New Zealand|
|Date:||Apr 1, 2009|
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