Professional, Practice and Political Issues in the History of New Zealand's Remote Rural 'Backblocks' Nursing: The Case of Mokau, 1910-1940
Wood, Pamela J., Contemporary Nurse : a Journal for the Australian Nursing Profession
The new role of 'backblocks' nursing, established in 1909 to provide a nursing, midwifery, emergency and public health service to New Zealand's remote rural regions, created opportunities and challenges for the profession. For three decades, the novel nature of the role also provided numerous stakeholders with the opportunity to contest their authority and influence.This article explores the professional, practice and political issues of backblocks nursing through a case study of Mokau, a remote rural community in the North Island of New Zealand, 1910-1940. In particular, it considers professional issues of recruitment and retention, practice issues in delivering the new service in a challenging environment with few resources, and political issues in defining the scope of nurses' practice and dealing with competing stakeholders keen to determine its potential and limits.These issues were exacerbated by the location of the Mokau district in two administrative health regions.
rural and remote
nursing; backblocks nursing;
Received 23 August 2007 Accepted 25 June 2008
British colonial settlers arrived in New Zealand in increasing numbers from the 1840s, as part of the planned settlement of the country at the farthest edge of the British Empire.When the colony became a Dominion in 1907, settlers were still opening up land in its remote, isolated regions. In 1909 the New Zealand government introduced a scheme to provide a health service for these settlers - the Backblocks Nursing Scheme. The general history of this service has already been described (McKegg 1991).This article, however, explores professional, practice and political issues in backblocks nursing through a case study of one specific area, Mokau, a remote rural community in the North Island of New Zealand, 1910-1940. It examines in particular the professional issues of recruiting and retaining nurses for this post, practice issues in delivering the new service, and political issues in defining the scope of nurses' practice and dealing with competing stakeholders keen to determine its potential and limits.
BACKBLOCKS NURSING SCHEME
The idea for a nursing service for settlers in remote rural areas was proposed by Dr THA Valintine, New Zealand's Inspector-General of Hospitals, at a hospital board conference in 1908. Although living in the country's capital, Wellington, he was familiar with backblocks settlers' needs from his previous role as a rural doctor in Taranaki, a region in the west of the North Island of New Zealand.What the country needed, he said, was a health system that would 'make itself felt in all parts of these Islands', not only in districts immediately surrounding towns, as was then the case, but also 'in the far remote country districts - the backblocks'. Government subsidies had been insufficient to persuade doctors to settle in these regions so he suggested the districts would be better served by a district nurse who could keep in telephone contact with 'a doctor at a distance'. Such a service would be a boon to settlers 'facing the discomforts and hardships of backblocks life' and the nurse would 'supply the link in the chain' between the base hospital and its remote region (Valintine 1908).
The Backblocks Nursing Scheme, established the following year, provided a nursing, midwifery, emergency and public health service to Pakeha (European, mostly British) settlers living in remote regions. A parallel Maori (or Native) Health Scheme was established for the mostly rural, Indigenous Maori population in 1911 (Mc- Kegg 1991; McKillop 1998). By the 1920s the boundaries between the services had blurred. The backblocks scheme enabled settlers' groups to ask their hospital board for a nurse to be appointed in their isolated community. If settlers promised to meet half the nurse's salary and expenses, the hospital board would employ the nurse and use a government subsidy to pay the remainder.The Department of Health oversaw her work.The nurse decided which level of fee, on a set scale, patients would pay for her service. She sent the fees to the hospital board where they offset the amount guaranteed by the community. Settlers paying a local subscription were charged less and the nurse could waive fees if patients could not afford to pay.
The backblocks scheme gave hospital boards the chance to meet their obligations to care for rural as well as urban people in their districts at minimal cost. It enabled settlers to take the initiative in obtaining a health service they needed and ensured them help in times of childbirth, sickness and accident, when distance made medical help inaccessible or too expensive to request. As farming was the basis of the country's economy, the scheme enabled the government to show settlers it valued their effort and contribution, and that it considered those in rural areas had the same right to a health service as their urban counterparts. In time, it gave the Department of Health a means to extend its public health agenda into rural New Zealand. The scheme offered the nursing profession an expanded role with a new direction for practice, as well as the opportunity to show its value to a health care system seeking to respond to increasing and changing health service needs. At the same time, it challenged nursing leaders' efforts to find sufficient nurses to fill the positions arising from settlers' expectations for the new service. And for nurses taking on the role, it provided a chance for independent practice and greater responsibility, far from the hierarchical systems and practice in hospitals. It also challenged them to adapt their practice to nursing under difficult conditions with few resources, and manage the social, professional and political demands of working in geographic and professional isolation, sometimes with the resentment of the districts' doctors who felt their income would be threatened.
In this way, the new role had various stake- holders: government policy-makers, groups of settlers, hospital boards, Department of Health officials, doctors, individual nurses and the nursing profession.The novel and emerging nature of the role provided an opportunity for them to exercise their authority and influence. The involvement of all of these stakeholders is particularly highlighted in the case of Mokau, which acts as an acute example of the issues faced in other parts of the service. These issues were also often experienced by nurses in remote, rural regions in other countries.
Nursing schemes for remote rural regions had already been established in other countries. In Britain, isolated communities sometimes had their own scheme through local philanthropy but gradually the Queen Victoria Jubilee Institute (QVJI), set up in 1887, provided much of the service and became the model for other schemes. Lady Aberdeen, wife of Canada's Governor- General, used it as the basis for the Victorian Order of Nurses (VON) in Canada in 1897, marking Queen Victoria's Diamond Jubilee. Much later, Mary Breckinridge saw the model at work in the Scottish Highlands and Islands scheme, established in 1912, and used it in 1925 in forming the Kentucky Frontier Nursing Service in the United States of America (USA), in a mountainous region she felt was geographically similar to remote areas of Scotland. Other people of social standing and influence spread the idea elsewhere. Lady Dudley, whose husband was Ireland's Lord Lieutenant 1902-1905, established a scheme there and in 1910 tried to transport the idea to Australia when her husband was Governor-General.Vocal resistance from some Australians annoyed with her approach, however, meant that the 'bush nursing' scheme required the deft and politically astute intervention of Amy Hughes, Lady Superintendent of QVJI, to see it successfully established, with its first nurses appointed in Victoria and New South Wales in 1911. Remote nursing services also began through missions, and large organisations such as the Red Cross rural nursing service in the USA in 1912 and the Canadian Red Cross nursing outposts after World War I. There were also government schemes such as the Medical Service to Settlers which, despite its name, provided a nursing service for remote areas of Quebec from 1936.
New Zealand's scheme was not part of the spread of a British model to some of the empire's colonies through aristocratic influence, as in the case of the VON in Canada and bush nursing in Australia. In New Zealand, local influence and initiative, arising from direct backblocks experience, saw it established two years before bush nursing in Australia, its closest neighbour, and without the QVJI as its model. Hester Maclean, New Zealand's chief nurse,1 1906-1923, and owner-editor of the country's nursing journal, Kai Tiaki, noted in 1910 that a 'simultaneous wave of thought and care' had passed through many countries with large, sparsely settled parts, leading to similar schemes for the relief and help of those living far from cities (Maclean 1910). This view of simultaneous development far more accurately represents the reality of the establishment of remote rural services in various countries at this time, than imperio-centric accounts that assume only British initiation and a motherland-to-colony spread of ideas, nurses and nursing services. Even when British nurses from the Colonial Nursing Service went to South Africa, as Helen Sweet has explained, it was not as an initiative from Britain but the result of recruitment from the colony once a need was locally determined. They 'did not establish, but were sent by formal request to supply an existing need' (Sweet 2004: 183 - italics in original). Although the various 'frontier', 'outpost', 'settler', 'bush' and 'backblocks' schemes might have been different in their establishment and organisation, nurses faced similar professional, practice and political issues.These have been described, for example, for Britain (Baly 1987; Gibb 1992/93; Howse 2007), Canada (e.g. Bramadat & Saydak 1993; Dodd, Elliott & Rousseau 2005; Elliott 2004; Rousseau & Daigle 2000), the USA (e.g. Apple 2007) and Australia (e.g. Bardenhagen 2003). This case study shows how these issues were experienced in one small place, Mokau.
ESTABLISHING THE BACKBLOCKS NURSING SCHEME AT MOKAU
With Valintine championing the scheme from his experience as a rural doctor in the Taranaki region, it is not surprising that Taranaki settlers were the first to request a nurse once the scheme began in 1909. Settlers at Uruti assured the Taranaki Hospital Board they could pay half the costs and the hospital board, on advice from the Department of Health, appointed Margaret Bilton to the tiny settlement and its large hinterland. Outside her district to the north, beyond Mt. Messenger, lay the black-sand mouths of the Awakino and Mokau Rivers, just a few miles apart. Settlers there, and others dotted throughout the region, saw the scheme's success and within a few months had banded together to request a nurse. Their decision to combine forces was geographically sensible but complicated their request, as their area sat across two hospital board regions.The southern of the two rivers, the Mokau, marked the traditional boundary between Maori iwi (tribal) areas - to the north,Tainui, and to the south, Taranaki - and was now the boundary between the Waikato Hospital Board to the north and the Taranaki Hospital Board to the south. Settlers on the two sides of the river were therefore located in different hospital board regions. Those on the southern side could not be covered by the Taranaki Hospital Board's nurse at Uruti, even if she had had time to do so, as Mt Messenger presented an effective barrier. It took some hours to travel over the narrow, barely formed roads winding up and around its steep slopes.
As most of the rugged Awakino-Mokau area lay within the Waikato Hospital Board region, the settlers approached that board in 1910 but also wrote to Valintine for his 'sympathy and assistance', hoping that as he knew their district he would 'understand the urgency' of their cause. The nearest doctor was 50 miles away from Awakino, but at an even greater distance for those in their area who lived further inland (Leech 1909).2 Valintine advised them to wait until the new Hospital and Charitable Institutions Act, passed the previous year, came into effect in April (no doubt because this would make hospital boards' obligations clearer). In the meantime they would be wise to canvass settlers to ensure they would guarantee their contribution to the nurse's salary and expenses, a sum of about £200. Knowing the area's isolation, he believed they had a just claim and he would do his best to 'enlist the sympathies' of the hospital board (Valintine 1910).
This initial request was unsuccessful.The settlers decided they would perhaps have more political weight if they set up a formal association along the lines of the one at Uruti. These associations were simply groups of settlers banding together to make a case for a nurse, show the department their willingness to commit money for their share of the cost involved and have the stronger voice provided by collective rather than individual effort. The exact association membership is unclear although their correspondence with the department suggests the president and secretary (and perhaps all members) were men.
The Awakino and Mokau settlers wrote to Valintine in 1914 advising him that they had formed a District Nursing Association that would have its headquarters at Mokau.They had obtained for a nurse 'two comfortable rooms in a private house' occupied by a 'respectable married couple with two children'.They were anxious for a nurse to be appointed before the winter set in and hoped Valintine would help them 'get over any obstacles' they were likely to meet. They also wondered if they would 'have any voice' in selecting the nurse as they felt it was even more essential than in Uruti that she was highly trained and thoroughly competent, as in winter they were at least six hours away from a doctor (Carr 1914a; Jacobs 1914a; Jacobs 1914b).Valintine advised that the choice of nurse should be left to the department as it had information about the qualifications, capacity and suitability of any nurse for backblocks work (Valintine 1914a;Valintine 1914b). He passed the matter to Hester Maclean who, in contrast, had no hesitation in welcoming any suggestion the association might have if they knew of a suitable nurse, as she found it exceedingly difficult to get nurses to take these positions and not many had the requisite training and experience. She asked if it were necessary for the nurse to know how to ride a horse already or whether she could learn at Mokau (Maclean 1914a).
From this point, the story of backblocks nursing at Mokau demonstrates the various opportunities and challenges associated with the development of this role throughout the country. The first problem was one successive nursing leaders encountered: finding sufficient nurses for the positions and retaining them once appointed.
RECRUITMENT AND RETENTION OF BACKBLOCKS NURSES
The backblocks nurse took care of the sick, attended women in childbirth and supported them with their new babies, responded to accidents in the bush and helped improve sanitation, hygiene and public health in their districts.They therefore needed sound expertise in nursing and midwifery, both of which had required formal training and an examination to achieve state registration since 1901 for nursing and 1904 for midwifery. Nurses would ideally also have experience beyond hospital boundaries and some idea of public health measures.Working in geographic and professional isolation, far from a doctor and with few resources, they needed to be able to act decisively, responsibly and with some creative flair, as well as manage the loneliness, discomfort and sometimes hardships of backblocks life. Although the chance for independent practice appealed to nurses, Maclean and her successors had continued difficulty in finding nurses to fill the positions. The case of Mokau offers a good example.
In April 1914, Maclean offered the position to Gertrude Garrard, a nurse who had registered in New Zealand in January that year, but who had completed her training in Launceston, Tasmania, in 1912. She accepted the position but wanted 'a month or so' in Wellington before going to Mokau as she had just settled into the nurses' club in the city (Garrard 1914). On her behalf Maclean wrote to the association in early May to check that Garrard's expenses getting to Mokau and her lodging there would be paid for by the association, as at Uruti. She warned them that to have Garrard there before winter set in, and not lose a nurse with good experience who was anxious for district work, an appointment would need to be made very soon (Maclean 1914b). The secretary, JB Carr, replied that as their association was only just starting it was hardly fair to expect as much from them as from Uruti. In time they would build a cottage that would be available rent free to the nurse but at present she would have to pay her own way, including expenses in getting to Mokau. They could offer her a bedroom, furnished except for bedding, with a fireplace, for six shillings a week and meals at nine pence each. She would be 'driven to and fro as required' but at odd times might have to ride a horse and would have ample opportunity to learn to ride once there (Carr 1914b). Garrard agreed, as long as her travelling expenses to Mokau were refunded after six months. Maclean advised the association to accept this, again reminding them that it was extremely difficult to get nurses ready to take up these positions (Maclean 1914c).Two days later, however, and probably feeling both annoyed and embarrassed, she had to report that as a severe illness some time previously had apparently left Garrard with neuritis, the nurse now felt it unwise to 'face the wet season in Taranaki' (Maclean 1914d).
In June, Maclean offered the position to Ada Roberts, an English nurse who had come to New Zealand to nurse 'a dear friend' in Auckland. She accepted and anticipated she would be able to start late the next month (Roberts 1914b). At the end of July, after a week at Mokau, Roberts told Maclean and Amelia Bagley, the nursing inspector who supervised backblocks nursing, that she was quite settled and happy. Although she had not had many patients yet, everyone seemed pleased to see her and she hoped to be 'useful in time of need' (Roberts 1914c). She had enjoyed her first horse rides, one for sixteen miles partly along the beach, which was 'grand' (Roberts 1914a). Within three months she had resigned.
Again the settlers asked for a suitable nurse, this time preferably a 'colonial' one (Lepper 1914). Maclean preferred them too, as she told the hospital board, but they were not easy to find (Maclean 1914g).The reference to colonial nurses did not mean those of the Colonial Nursing Service, who did not come to New Zealand but went usually to colonies with tropical climates (Sweet 2004; Jones 2004; Rafferty 2005; Rafferty & Solano 2007). According to Maclean and others, the key advantage of New Zealand (i.e. 'colonial') nurses was their ability to 'rough it' in the backblocks. In 1918 Maclean noted that the trying conditions were difficult enough for those born and bred in New Zealand but for nurses from England it was far worse (Maclean 1918). This is perhaps the reason she only actively recruited overseas nurses once, in 1912, through the British Women's Emigration Association, although it was a strategy used successfully by schemes in other countries (Maclean 1932).3 Nurses came individually, however, to join the scheme. As McKegg (1991) has shown, of the 21 nurses in the scheme in its first decade, eleven had trained in Scotland, England or Australia. The one who had been a Queen's Nurse in Edinburgh would have received training in district nursing and another who had worked in the west of Scotland would have been familiar with a rural context. No formal preparation was available for backblocks nurses but some who joined the scheme had usefully experienced nursing in exceptionally difficult conditions, in caring for patients in tent hospitals in remote areas during typhoid fever and smallpox epidemics.
As at Mokau, another difficulty arose in retaining nurses once appointed. Many did not stay long. As McKegg (1991) has also shown, of the 46 nurses working in the backblocks between 1909 and 1930, 10 stayed less than a year, 15 stayed for 1-2 years, 9 for 2-5 years, 10 for 5-10 years and only two for up to 20 years. They left for further training, hospital positions, private nursing, retirement or wartime service overseas. Nearly half left to marry. Some relinquished positions through illness and three died. Roberts left her Mokau position for marriage (Jacobs 1914c).
Despite the difficulty, by December 1914 Maclean had found another nurse,Theresa Butler, who was able to start in January. She had trained and been a sister at Christchurch Hospital in New Zealand, qualified as a midwife in Melbourne and had just returned from England - one of two New Zealand nurses who had gone to Brussels at the outbreak of war but had been ordered out by the Germans. She could not ride but expected to learn quickly. Maclean considered her well qualified for the position (Maclean 1914f). As the board would not, however, pay her travelling expenses from Wellington, Butler declined the position. In her letter notifying the Mokau settlers, Maclean's frustration is clear (Maclean 1914e). She showed her displeasure to the board, reminding them that it was very difficult to get nurses for these appointments. It was a pity Butler's request for expenses was refused, sniffed Maclean, as her recent return from overseas meant she was probably not able to afford the expense of getting to Mokau (Maclean 1915). Fortunately for all, Ivy Holdsworth, an English midwife in the rural settlement of Apiti by the Ruahine Ranges in the North Island's Manawatu region, was about to close her private maternity home and wanted a backblocks position. She had 'put all [her] fish into the one net and not saved a sprat' but hoped for another year in New Zealand (Holdsworth 1915). The Mokau settlers agreed, somewhat reluctantly, to pay her travelling expenses as long as she remained a year (Carr 1915).
As Holdsworth was a midwife with only a two-year nursing certificate, she was not able to register as a nurse in New Zealand, which from 1901 had required completion of a three-year training course. Nurses with the required qualifications, experience, personal attributes and desire to work in an isolated area were hard to find in the numbers needed, whatever the location. Similar services in other countries also occasionally overlooked qualification standards in times of need (e.g. Bardenhagen 2003). Once Holdsworth was appointed, Maclean advised the settlers that as so many nurses were away on wartime service, the Mokau and Uruti associations should both use her services as much as possible until the war was over (Maclean 1916). Despite the practical difficulties of working both regions, given the obstacle of Mt Messenger, Holdsworth remained there until 1918 when she took a similar position at Opunake, another rural community in Taranaki. Attempts to appoint and retain a nurse in the Mokau position continued sporadically over the next decades, with the Awakino and Mokau settlers even invoking the assistance of their separate Members of Parliament to make a special plea to the Minister of Health - a strategy they were to use again later for a different purpose (Bollard 1923; Rolleston 1923).
CHALLENGES IN BACKBLOCKS NURSING PRACTICE
Nurses had to adjust quickly to 'roughing it' in the backblocks.They lived in rooms in private homes, such as the lodging arranged by the Mokau settlers, or eventually had a cottage built or rented by the service. Little time was spent there, however, as they frequently nursed people in their tents, slab huts or small homes on farmland or in the dense bush for days or weeks at a time, with little privacy. Even living in their lodging or cottage, they spent many hours struggling to get about the district to reach a series of patients in the one day.They traversed the difficult terrain on barely formed roads, tracks and bridle paths, in mud or dust, by horse, buggy, coach or foot. Launches transported them to settlers at the distant reaches of rivers, and railway jiggers to work settlements in the bush.
The Mokau district comprised a narrow coastal strip with black iron-sand beaches and a rugged inland terrain of high hills with rocky outcrops, covered in dense native rainforest ('the bush'), steep-walled narrow rock gorges and a few open areas cleared for farmland (Mc- Lintock 1966). Fortunately the long, winding Mokau river was navigable and a ferry shunted people, vehicles and animals from one side of the river mouth to the other. Most of her patients would have made their living from farming, logging, open-cast coal-mining and fishing, so dealing with accidents as well as births and illnesses would have formed part of her work.The nearest main hospital was at New Plymouth on the coast to the southwest, past the obstacle of Mt Messenger and beyond the Uruti nurse's patch. Although a doctor at Waitara could be reached on the way, he was still several hours distant. The extent of any backblocks area was measured more in travel hours and topographic difficulty than in miles.
Backblocks nurses enjoyed telling colleagues how the work contrasted starkly with hospital nursing.They particularly emphasised the difficulties of transport and terrain, adapting practice to nurse people under trying conditions, being as resourceful as settlers in 'making do' with minimal equipment, and carrying on for what seemed like endless hours or days with little respite between cases.They were never officially off-duty. Nurses also had to be politically astute in dealing with local committees, such as the association at Mokau, fitting into a rural community, and managing a working relationship with medical colleagues at a considerable distance, who sometimes resented the loss of income that the backblocks nursing scheme represented. Nurses in remote rural areas in other countries faced similar conditions and wrote similar accounts (see, for example, Apple 2007; Baly 1987; Bardenhagen 2003; Bramadat & Saydak 1993; Dodd et al 2005; Elliott 2004; Rousseau & Daigle 2000).
Nurses were repeatedly reminded by superiors that they were to work specifically under medical instruction. They were not to take on the role of the doctor, nor assume they had that extent of knowledge and expertise. On the other hand, they were to step in and act decisively when medical advice was not available. Nurses needed considerable political savvy in managing these conflicting directives.4 They enjoyed the freedom and independent practice of backblocks nursing, yet were keenly aware of the significant responsibility they carried.They skilfully made critical decisions in the absence of a doctor yet were relieved to have their decisions affirmed when a doctor could finally attend the patient. Ada Roberts, in her first week at Mokau, told Bagley that a doctor had travelled through one day and was satisfied with what she had done, even saying that he could not have done more himself, so she felt 'bucked'. Nevertheless she worried, as many nurses did, about keeping up to date with changing practice and having sufficient knowledge to make independent clinical decisions. She admitted to Bagley that she sometimes felt how little she knew, particularly as she was 'thrown so much upon [her] own responsibility'. She had a nursing textbook but asked Bagley to recommend 'something deeper in the medical line' (Roberts 1914a).
Although the Mokau nurses' nearest colleagues at Uruti wrote articles and spoke to nursing audiences about their work, no published account of backblocks nursing at Mokau is evident, possibly because journal articles seldom carried a nursing author's name at that time. Margaret Bilton was an exception but as the first backblocks nurse, and the first to write about the new role, she would have been identifiable regardless of having her name published (e.g. Bilton 1913). Her successors carried on the tradition (e.g. Kelly 1914). Nor were snippets of Mokau nurses' letters to Maclean included (as those of several others were) in her reports of backblocks nursing in the journal. One 1933 account of backblocks nursing, however, would have been very close to the Mokau nurses' experience, even though this nurse lived up a river rather than at its mouth. She made an early start one morning to catch the cream launch down the river, rode five miles on a butcher's lorry, then tramped three miles over sand hills to reach her patients. Late in the afternoon she got a lift in a passing car in order to catch the launch home, then rode on horseback to a woman giving birth (Kai Tiaki 1930).5 This was typical of several accounts describing the long hours and variety of transport modes used in one day. What is recorded about the 1930s Mokau nurse's work, however, is her difficulty getting about the district and the impact this had on the scope of her practice. It was this issue that stakeholders seized to contest their authority and influence.
CONTESTING AUTHORITY OVER THE ROLE
A key political difficulty in the Mokau nurse's work was that her district lay in two hospital board and Department of Health areas.With the increase in the public health aspect of the nursing role in the 1920s, the department's medical officers of health in both regions wanted to use her services more. In August 1935, one of the Taranaki officers, Dr Mary Champtaloup, was the first to alert the Director- General of Health, Dr MH Watt, that the Mokau nurse needed a car in following-up Maori patients with tuberculosis, south of the Mokau River (Champtaloup 1935a).Watt (1935b) replied that if her work were seriously impaired by lack of transport, he would take the matter up with the Waikato Hospital Board (who technically employed her). Seeing either the opportunity to persuade Watt in the matter or to expand the scope of her own public health work even further, Champtaloup (1935b) said that although Nurse Sinclair was doing excellent work she was 'unduly taxed' by her present transport arrangements. If a car were provided she would also be able to undertake follow-up work arising from health checks in schools. Watt (1935a) duly wrote to the board setting out the reasons and benefits, even promising to pay a mileage rate for running the car on preventive work, but the board did not take up the suggestion.
Champtaloup and her colleague, Dr FWW Dawson, made further requests in the following years, again supported by both Watt and the Mokau settlers. In 1936 Dawson (1936) pointed out that as patients' relatives were often unable to send a car the nurse got about, with her heavy bag, by bus or free rides with bakers, carriers or any other passing vehicle.The previous year she had covered nearly 6,000 miles in this manner. She therefore spent a large portion of her time on the side of the road waiting for transport. This time, Dr HB Turbott, the medical officer for the Waikato region, stepped in, decidedly against the notion. In his portion of the nurse's district there were only three river settlements. Focusing on the lack of potential for preventive work, he noted that Mokau and Awakino had small schools, the tiny settlement of Whareorino with thirty families had only nineteen children in its school, and there were perhaps a dozen further families living along the Mokau River. In addition there was a summer migration to Mokau of possibly 200 Maori. As she was already doing the work without a car, providing one was quite unnecessary (Turbott 1936).
Matters came to a head in 1938. Dismayed at the lack of action in fixing the nurse's transport problems, the settlers in Awakino and Mokau again contacted their respective Members of Parliament.They made it clear to WJ Broadfoot (Te Kuiti) and WJ Polson (Stratford) that because the nurse 'struggled on' without a car her working day extended to sixteen hours. They pointed out that keeping patients out of hospital saved the hospital boards money and should sway decisions (e.g. Gilliver 1938; Polson 1938). The Minister of Health, Peter Fraser, passed the matter to Watt who again wrote to the Waikato Hospital Board to strongly recommend the grave necessity of purchasing a car as the nurse was greatly hampered (Watt 1938c). He also wrote to Turbott, courteously notifying him of his communication to the hospital board in his region. It was this memorandum that triggered the strongest reaction.Turbott sniped back that Watt had apparently overridden his opinion, that the hospital board would only buy a car if the department continued its pressure, and the department had a very weak case.With anger clearly stoking his argument, he added that he had tried to use the Mokau nurse for school and preventive work but she had not co-operated. The cases of scabies and impetigo in the Mokau School were evidence of this. She was 'too set in her curative ways', was also 'anchored' in them by the association, and seemed 'too old to alter' (Turbott 1938).
Watt asked the department's Director of the Division of Nursing, Mary Lambie, for her opinion. It was duly recorded in a small annotation across the lower left-hand corner of Turbott's acerbic memorandum.Amid the sometimes strident views of various stakeholders, her simple statement that the nurse was 'considerably handicapped in her work owing to lack of transport' confirmed Watt in his action. He wrote again to the board providing details and statistics of her work, and told Turbott his decision (Watt 1938a;Watt 1938b). Representatives of both the hospital boards and regional health department offices, and 20 members of the settlers' association, met at Mokau in August to work out arrangements (Department of Health 1938). Finally in November 1938, the Mokau nurse became the proud and no doubt relieved driver of a 10 horse-power, two-door Ford, with the front passenger seat able to be folded back to carry a person lying down (Waikato Hospital Board 1938).
This example shows how the novel and emerging role of the backblocks nurse was regarded by different stakeholders as theirs to influence. The settlers using the Mokau nurse's services saw the practical impact a lack of transport had on her working day and tried to make a difference for her, engaging parliamentary support to do so. The hospital board nominally responsible for her employment saw providing a car simply as an added expense. Champtaloup and Dawson saw it as a means to deal with the nurse's need for efficient transport, as well as an opportunity for them to engage in more preventive work by extending her role.Turbott regarded the matter with a population-based approach to delivering a health service, rather than seeing it in terms of the nurse's practical difficulty and the particular situation generated by the district's isolation.Turbott clearly believed his opinion should hold sway, delivered as it was with dense details from his own observation of the area and his (rather snide) judgement of the nurse's ability.Watt agreed with the settlers' and Taranaki doctors' arguments, however, and used Mary Lambie's calm confirmation of the problem to do the best he could within his authority to persuade the hospital board.
The case of backblocks nursing at Mokau reveals the significant issues faced in establishing and providing this service in remote rural regions of New Zealand. Nurse leaders wanted to show the profession's ability to respond to changing health needs and to have a new field of practice open for nurses but had insufficient nurses to fully achieve the potential the new service represented. Nor could they fulfil the expectations of settlers who increasingly called for nurses in their isolated communities. The pressure to fill positions meant that at times the requisite qualifications were set aside and as elsewhere in the country a midwife with insufficient training to achieve nursing registration was appointed.While recruitment was a problem, so was retaining nurses once in the position. The continuing change of nurses at Mokau, with some there for only a short time, exemplifies this difficulty.
Nurses taking up the role at Mokau and elsewhere faced challenges in adapting their hospital practice to nursing settlers in tents or rough dwellings, coping with few resources, travelling through the rugged physical terrain and living in the community's continuous gaze. The geographic and professional isolation provided a welcome opportunity to practise independently, even with the political challenge of conflicting directives about following doctors' instructions. Nurses were keenly aware of the significant responsibility this involved, as Ada Roberts's comments and request for a medical text book indicate.
The fact that the Mokau nurse was located in two hospital boards' and regional health offices' jurisdictions exacerbated the professional, practice and political issues encountered by nurses throughout the backblocks service and often experienced in similar schemes in other countries. As a new role that continued to change through the three decades, its malleable nature also provided an opportunity for various stakeholders to test their authority and influence in shaping it. In Mokau, this centred in the 1930s on the nurse's need for a car to alleviate the long working day and respond to requests to expand her practice.The regional health offices and hospital boards jostled for position in order to decide on appropriate expenditure and the scope of the nurse's practice. Settlers' voices added to the clamour and their engagement in the issue brought parliamentary members into the argument. The department did its best to resolve the tensions but could only make a strong case and hope to persuade the hospital board responsible for expenditure.Turbott considered his views supreme and demonstrated the same outspoken disregard for how he was perceived by others that delayed his promotion to Director-General by almost ten years and polarised people once he held that position.The tussle over whether to provide the Mokau nurse with a car highlighted the number of groups and individuals with a stake in the outcome. The vehemence of the argument indicates the extent to which they valued, or devalued, this new role in making a difference to their professional or personal lives.
1 Her official title was Assistant Inspector of Hospitals but in this central government role she had oversight of all nursing matters in the country, regardless of setting. This was reflected in her change of title in the 1920 restructuring of the department, to Director, Division of Nursing.
2 This letter is dated 1908. The date must be incorrect as he mentions the nurse at Uruti who was not appointed until 1909. It is reasonable to suppose he wrote the letter in February 1910 as he received a reply in March 1910.
3 Overseas recruitment was used, for example, by the New South Wales Bush Nursing Association consistently and successfully through the 1920s. New South Wales Bush Nursing Association records, 2815, 14(65), K48710, Mitchell Library, NSW. It used the Society for Oversea Settlement of British Women, which had been formed when several groups merged, including the British Women's Emigration Association (Pickles 2002).
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PAMELA J WOOD
Graduate School of
Wellington, New Zealand…
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Publication information: Article title: Professional, Practice and Political Issues in the History of New Zealand's Remote Rural 'Backblocks' Nursing: The Case of Mokau, 1910-1940. Contributors: Wood, Pamela J. - Author. Journal title: Contemporary Nurse : a Journal for the Australian Nursing Profession. Volume: 30. Issue: 2 Publication date: October 2008. Page number: 168+. © eContent Management Pty Ltd Apr-Jun 2009. Provided by ProQuest LLC. All Rights Reserved.
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