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Relishing the challenges of rural nursing: an experienced rural health nurse reflects on her work and the shattering experience of having her application to become a nurse practitioner turned down.

MARG ECKHOFF, leader of an on-call team of rural health nurses in a Central Otago valley, is no quitter. But she's had enough. Enough of what she sees as nursing academics ruling the professional roost. Enough of many of those nurses having no understanding of her work and what it means to the community she serves. Enough of having to gain further academic qualifications to advance professionally. After having her application to become a nurse practitioner (NP) in primary health care turned down twice, the second time on appeal, she has decided she will no longer pursue that avenue for professional advancement or do further academic study. It's a decision she has not taken lightly or without regrets. But it is has brought her and her family a great deal of relief. And the experience has not put her off the job she loves.

Eckhoff, originally from the Maniatoto in Otago, decided on nursing as a career in her last year at school, a decision she has never regretted. Just before she graduated in 1973, she married farmer Gerry Eckhoff. The couple subsequently had four children, the youngest of whom is now 20 and studying nursing. She did some casual work at the Lumsden Maternity Hospital, cared for the children and became involved in the La Leche League, inspired by her own problems breast-feeding.

In the mid-'80s, the family shifted to Roxburgh and in the late '80s she began work as a casual nurse at the hospital there. She also began helping out at the women's clinic at the local general practice, while "keeping a hand in" at the hospital, until it closed in 1995. As well as her work at the women's clinic, she began doing immunisations. "I grew into practice nursing. And when I started nursing again, I did every possible course I could. It was like I retrained."

In 1996, two new GPs were prepared to come to Roxburgh on condition they got help with on-call work. A pragmatist and deeply committed to her community, Eckhoff established an after-hours nursing team, called the nurse practitioner team. "I'd read about what nurse practitioners were doing in the United States and it was very similar to what our team was doing and the name seemed to capture the breadth of our work," she said.

A stable team, well supported by the GPs, developed, with Eckhoff as team leader. She promoted the concept tirelessly, thinking it might have application in other rural areas struggling to keep their GPs because of the grind of on-call work.

The community was nervous of the nursing team at first. "We knew the community was watching us very closely and that it would be less tolerant of a nurse's mistake than a doctor's. But we've proved our value over and over again."

There have been some changes to the team but Eckhoff remains as co-ordinator. Some of the nurses come from outside the area and stay in Roxburgh for their on-call weekend. The on-call nurse works from 5pm Friday to 9am Monday and has the full range of emergency equipment available, They have a car, two pagers (one receives 111 calls) and a cellphone. The nurses are employed by the Roxburgh Medical Trust, which also contracts the GPs. The trust bought the local general practice in 1995 and it is run by a board of local people.

As well as all the equipment, and their specialist skills, Eckhoff says a sense of humour is essential. All are able to insert intravenous (IV) lines, and can intubate patients, thanks to their PRIME (primary response in medical emergencies) training. "We can give emergency care on the spot. I believe it's the best cover this district has ever had."

One of the four nurses is on call a weekend a month.

The nurses also have basic plastering and suturing skills. "The emergency component of our work is actually very small compared with the rest of our work. Generally, it is similar to practice nursing work, if the nurse has been in a practice where she has been able to extend herself professionally."

On her last weekend on-call, Eckhoff received a 111 call. A farmer had had an accident on sloping ground on his four-wheel bike and had sustained an open fracture of his tibia and fibula. "We had someone stopping him from slipping, our emergency bags were propped up against the tussock and l had to put in an IV line. His pulse was 40, so I was unsure about administering morphine, but he needed pain relief as the helicopter was 20 minutes away. I rang the intensive care unit in Dunedin and the doctor there said to go ahead with the morphine 'but keep the atropine handy'. By the time the helicopter arrived he had pain relief and fluids on board and I didn't need the atropine."

Other calls over the weekend were for a prolonged nose bleed, a discharging ear, to a van that had run off the road, but no-one was injured, and some cuts and sprains.

As well as her on-call work, Eckhoff works as both a practice nurse and a nurse manager of community services. These include district nursing, meals on wheels, speech therapy, physiotherapy and home help. Her responsibilities include all reporting, accounts, consumer surveys, audits and staff appraisals for the team.

The rhythms of rural life are reflected in her work. "When it's shearing, we treat a lot of cuts. When it's the fruit picking season, we treat the results of falls from ladders and there's a lot of demand for the 'morning after' pill."

She is well used to "meat counter consultations". While occasionally they annoy her, she knows they are a mark of the trust the community has in her.

Eckhoff says rural people are very considerate and very stoic--"they can sit on chest pain all night".

A children's health camp held at Roxburgh often generates high demand. As do the huge traffic volumes passing through Roxburgh over summer, as holidaymakers head for tourist meccas such as Queenstown and Wanaka.

She enjoys having student nurses on clinical placement. "I love that teaching role."

When the diploma of primary rural health was introduced, Eckhoff was on the first course. She completed the certificate, including PRIME training. She then took time off and in 2001 finished the diploma. She found the mix of clinical and academic learning very useful and found some of the more academic aspects of the diploma challenging but rewarding. As part of her diploma, she developed an orientation tool for new rural health nurses in Roxburgh. "It was really practical and relevant to the job in our community."

Having completed the diploma, she was looking for a new challenge. The NP role was being developed by Nursing Council and Eckhoff thought that, with her diploma and years of experience in rural nursing, she would apply. She had been inspired by the words of the then Nursing Council chair Judy Kilpatrick, quoted in Kai Tiaki Nursing New Zealand. Kilpatrick had said "Experienced nurses within a particular scope of practice who have done some formal study will be able to become nurse practitioners and/or prescribers. A masters degree is not going to make you a nurse practitioner. It is clinical capability. We need to get the message out to nurses that experience is respected." (1)

She put together a professional portfolio, according to the draft guidelines provided by the Nursing Council. She believed then, and still does, her work is that of an NP. "I thought I did everything right and was proud of my portfolio." She sent her application in April last year. When she had not heard anything from Nursing Council by August, apart from an acknowledgement that her application had been received, she decided to ring and find out what was happening. The person who responded to her query told her she was just about to write and tell Eckhoff her application had been unsuccessful. This was confirmed by letter, which suggested she do a clinical masters.

She subsequently realised her portfolio should have been more detailed but had thought that detail would be elicited during the interview process. "But I never got past first base so had no opportunity to expand on what was in nay portfolio."

Eckhoff says she was "gutted" by the decision. "My first reaction was that I had failed. I then went through a real grief reaction--tears, anger, disbelief. I kept remembering Judy Kilpatrick's words about clinical capability. They sounded hollow. It really shook my confidence. And it seemed so ironic that I had been asked by [rural health nursing lecturer]Jean Ross to help develop a clinical masters and here I was being told I had to do one."

Once over her initial shock and disappointment, Eckhoff decided to appeal the decision. She look time off work to attend the hearing and was accompanied by a support person. It was not a process she would like to repeat. She was also very disappointed no rural health nurse had reviewed her portfolio or was on the panel. "You have got to live rural health nursing to understand. They wouldn't have a clue unless they do it or spend time with us gaining an understanding of our work."

And she remains annoyed that while the Nursing Council expected the highest standards from nurse practitioner applicants, it did not deliver the highest standards to those applicants by having the guidelines in draft form for so long.

It was several weeks before Eckhoff heard her appeal had been turned down, again with the recommendation to do a clinical masters. Her reaction was not as intense, second time round. But a sense of disillusionment and disappointment in the profession she loves remains. "I think there are a lot of academic nurses having a lot of say in the direction of the profession. I think they've lost the plot--lost contact with clinical nursing. It is the people on the ground who really understand and I feel those academic nurses are looking down on us. I'd like to say to them 'come and try my job for a while.'"

After spending more than $1000 on her application to become an NP, excluding loss of wages for time off work, and the intense disappointment, Eckhoff has decided to call it a day. "I can no longer justify to my family or myself spending any more money on it or any more time and money on academic study. Life is too short. It's a relief to have come to this decision. I can now get some balance back in my life. And I've still got a job I love."

That doesn't mean she will do no further updating or upskilling, eg further trauma nursing care courses, but just not through a clinical masters programme.

She remains concerned about the development of NPs: whether district health boards can afford them; whether those who take the time off to do the necessary study will be guaranteed a job on completion; whether it will drive a wedge between NPs and their nursing and medical colleagues; whether clinical experience is genuinely valued in the application process.

She says many nurses driving the NP role have no understanding of demands on rural health nurses. "They are living in isolated areas, working full time, often with a family. They have to pay for travel, pay for study, organise relief while they are away. It's a huge cost on the nurse's job and personal life. There are a number of rural health nurses and others feeling angry that their experience is not valued. It's very discouraging for older nurses. I know some have been put off applying to be come NPs because of my experience."

While still feeling "raw" from her experience, Eckhoff hopes that by speaking out, she will help rural nurses and other nurses who feel their clinical skills and experience are being devalued. "Nurses are afraid to speak out. I know I'm not the only one who feels like this."


(1) O'Connor T. (2001) Regulating New Zealand nurses. Kai Tiaki Nursing New Zealand; 7: 8, p20-21.
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Title Annotation:profile
Author:O'Connor, Teresa
Publication:Kai Tiaki: Nursing New Zealand
Date:Mar 1, 2003
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