Working with Whanau in the far north: Adrianne Murray is the country's first nurse practitioner to be endorsed in the whanau ora scope of practice. She is excited about offering much-needed primary health care services to isolated communities in the Far North. But there are some frustrations.

Adrianne Murray has had a pressure-cooker journey to becoming the country's first nurse practitioner (NP) in the whanau ora scope. Now running a mobile health clinic providing nursing services and some disease state management services to marae, kohanga reo and isolated communities and families in the Far North, Murray began her path to NP status in 2002.

Her employer, then as now, is Maori provider Te Hauora Te Hiku O Te Ika, based in Kaitaia. She has worked for this provider since 2001. Her first role was to establish a health clinic, offering free nursing services--Maranga Mai Clinic--in the dining area of the old nurses' home at Kaitaia Hospital.

While working at the clinic, Murray heard about the NP role and thought "it sounds like me". She also thought the role had much to offer an isolated rural region which had difficulty retaining GPs. She was inspired by the idea of family NPs she had read of in international literature. She began talking with her employer and the Tai Tokerau Primary Health Organisation about developing and implementing such a role, where that role might sit within regional health services and possible funding for the role. Aware that if she was to become an NP, she would have to do post-graduate study, she began working with Te Hauora, Northland Polytechnic and Auckland University about the possibility of post-graduate courses in Tai Tokerau. That work proved fruitful and in 2003 the first Auckland University post-graduate courses were offered through Northland Polytechnic. So after a 17-year break since graduating as a registered nurse, she, along with 24 other students, began postgraduate study.

Before returning home to Kaitaia in 1994, Murray of Nga Puhi and Ngati Haua descent, had worked for seven years at Whangarei Base Hospital specialising in medical nursing and cardiac rehabilitation. Before working with Te Hauora, she had worked at Kaitaia Hospital in medical services, and then as a practice nurse for four GPs in the town. It was in that role her passion for primary health care was nurtured.

At the end of 2003 she won a rural health nurse scholarship. "It was a wonderful bonus for me. It enabled me to streamline my studies and to study full-time."

She decided to apply for NP status and complete her masters, with prescribing papers, "in one hit". In August last year she handed in her NP portfolio and then finished her masters' studies at the end of the year. She was endorsed as an NP in March and is awaiting her masters' results. The NP portfolio was the hardest work of all One of the main reasons was that she was pioneering a new scope of practice--whanau ora. "I have had to develop and realty fight for the whanau ora scope and to convince the Nursing Council and others of its value and its advantages in terms of patient outcomes."

The whanau ora scope includes all age groups. "I can go to a marae with a kohanga and provide acute and chronic assessments for the kuia and kaumatua, and do the well-child checks for those at the kohanga. I have had to demonstrate that I am competent in all those scopes. My role is a primary health care nurse, Maori, so it makes sense to operate in a Maori way, within a Maori scope of practice."

Community networking

Her role is not confined to nursing responsibilities. "I network with community agencies all the time about a leaky roof, a family with no water tank, a family with no home. I have to collaborate with many agencies to ensure total health needs are met. You have to get the leaky roof fixed so the kids don't get asthma."

Murray has been ednorsed in the whanau ora scope, has demonstrated clinical competencies across the age span and has completed all requirements to become a nurse prescriber. But she cannot prescribe in her endorsed scope because it does not fall within the approved scopes of practice--aged care and child family health--for prescribing. It will require an amendment to the Medicines Act to have the whanau ora scope included for nurse prescribing rights and that is "disheartening and frustrating. The inability to prescribe, even when most of the drugs I would be prescribing fall within the aged care and child and family health scopes, is impeding my practice. I'm here to make a real difference to Maori health and I can't prescribe the drugs that will help, eg drugs for impetigo and chlymadia, and the morning after pill I work with people who have no phones, no public transport, no other health services and often no registered and warranted vehicles to drive the hour or more into Kaitaia." It also means an increase in paperwork and that she is beholden to doctors to sign prescriptions "and that is not a good message for our profession when I have fulfilled all the prescribing competencies".

But despite this major frustration--and Murray remains positive some solution wit[ be found--she is Loving her new role. And so are her turoro. "The people want continuity of care and that's what I can offer."

The only health services she can't provide are immunisations, as she is unable to provide the refrigeration necessary for the vaccines, and assessments for those on invalid benefits. But one of her goats is to talk with Work and Income New Zealand to change this. "There is no reason why an NP can't do those assessments."

Murray Leaves Kaitaia each day, except Monday, at 8.30am. Her territory stretches from Kaitaia to Pukinui in the north and from the west to east coasts in that area. It takes her between 30 to 45 minutes to get to most clinics. She returns to base around 4.30pm to check and complete any paperwork generated during the day. A laptop in the clinic means specialist referrals can be made from the van. On Mondays she remains in Kaitaia for any clinic maintenance and to follow up referrals, Laboratory reports and all the other connections she needs to make.

Despite the frustration over prescribing, Murray is "very excited" about her new role. "This is an exciting and challenging scope and it is very rewarding. I get to know our turoro and our communities so well. Every day is a different day for me. I can't think of a better job really."