Nurses on the Move: New Zealand Ear Nurse Specialists

Peggy Dryden, RN, MSN, MBA, MLS

Disclosures

January 20, 2005

Editor's Note
Medscape readers will remember that in our last eLetter we "traveled" to the cold northern terrain of Alaska. This eLetter interview takes us across the globe to the scenic coastline area of the Bay of Islands in
Northland, New Zealand to a rural community called Kerikeri. Margaret Hunt, Clinical Ear Nurse Specialist, who lives in Kerikeri, describes herself as the first ear nurse specialist in the Waikato area of New Zealand, where she has affectionately been called the "pus bus nurse." Marg describes how she started in this unique role.

Margaret Hunt, Ear Nurse Specialist, outside her truck in the far north of the North Island, New Zealand.

Question: Marg, what is your nursing background and how did you become interested in ear, nose, and throat (ENT) nursing?

Response: My nursing training was in the hospital system in the early 1970s, with registration as a general/obstetric nurse in 1976. Following registration, I worked at Waikato Hospital in Hamilton, in a variety of settings including medical, surgical, and orthopedics.

I honestly got into ENT nursing by default. I was looking for a change in nursing focus away from a hospital setting, when a vacancy arose in public health for a new position as a Mobile Ear Nurse in Waikato. The qualifications for the mobile ear nurse specialist position were, however, somewhat unusual in that in addition to nursing skills, the other skills necessary included being able to tow a 16-foot caravan, drive a large car, and a willingness to fix equipment when it broke!

My background includes a nursing education with a degree in Health Sciences (Nursing). I became a registered general/obstetric nurse in 1976. (I am currently studying for an Advanced Health Sciences degree in nursing, which will provide me with a Master's degree at this level.) After receiving my nursing degree, I worked in a variety of nursing areas, including medical, surgical, and orthopedic settings at the secondary level, as a "well child" nurse, as a general practice nurse, and as a mobile ear nurse specialist at the primary or community level.

Question: How would you describe the population served by the ear nurse specialist? Had ear infections been untreated in the particular population? Are there particular characteristics of this culture, lack of healthcare, or other variables that made ears a particular problem needing special intervention?

Response: There was a concern in New Zealand in the late 1970s about chronic discharging ears among the children within the Maori/Pacific Island populations. At the time, chronic discharging ears were accepted as "normal." For the most part, acute otitis media was untreated, resulting in tympanic membrane perforations. These perforations then became further infected through swimming or another acute otitis episode. It is now known that the Maoris, Pacific Islanders such as the Inuits of North America, and the Australian Aborigines are more prone to middle ear disease because of various physical characteristics such as face shape, the muscle properties of the Eustachian tube, and ethnic origin. Much of the Maori population is located in geographic areas away from mainstream healthcare facilities, which results in their travel of considerable distances to see a doctor or health professional. Fortunately, most areas are now served by visiting doctors each week. Health nurses are also available most days.

Question: How did your role as the mobile ear nurse begin?

Response: I became the first ear nurse in the Waikato area of New Zealand in 1978, and I have been in the nursing role ever since. I began in the Public Health sector, which is now know as the Community Health sector. At this point, I started visiting primary (elementary) schools around the region, treating children with chronic supperative otitis media that was prevalent. Not long after, I became known as the "pus bus nurse!"

While in the schools, I spent time instructing teachers and children about how to keep perforations of the ear clean and dry. However, for the most part, discharging ears became the norm for many families.

While delivering this health service to the community, I acquired a vast amount of valuable healthcare information concerning the history and knowledge of the community. Over time, the use of oral and topical antibiotics along with ventilation tubes (grommets, as they are known in New Zealand) has stabilized the prevalence of otitis media with effusion (OME), or what is commonly called "glue ear." I now see few children with chronic supperative otitis media and, instead, see more children with OME. (OME may require the insertion of grommets or ventilation tubes to aerate the middle ear until the Eustachian tube functions normally.) Consequently, I am now known as the "glue ear nurse."

Question: What kinds of procedures do you perform? How has the mobile ear nurse role evolved over the years?

Response: My main role now is primary prevention and family education. Procedurally, I am able to treat discharging ears with suction. (I use an operating microscope to do this.) I also perform wax and foreign body removal and take swabs for cultures. With the use of standing orders, I also administer topical drops. However, I refer children who need oral antibiotics to a general practitioner (GP).

Along with the GPs, I am available for postsurgical follow-up care. This allows me to be able to show parents and caregivers their child's ears through the microscope. With this knowledge, parents are then better able to be vigilant about the child's ear infections.

Question: What is a typical day like for you?

Response: I cover a large geographic region of Northland, New Zealand (It takes 4 hours to drive from the northern to the southern boundaries and 2 hours east to west). I drive a "camper van" or RV that has been converted into a mobile clinic that houses an operating microscope and an old dental chair. My itinerary includes visits to various communities on a regular rotation. Most days I'm in the van at 7:30 am, which allows me to arrive for the start of the clinic at 9 am. It usually takes me 60 to 90 minutes to drive to a community. Once I arrive, the van is plugged into a power source.

The set-up of the clinic inside the van takes only approximately 15 minutes. The visits are on a "first come, first served" for the children and their families. (There are no appointments, so I never know what or how many people are coming!) Generally, however, there are usually around 25 to 40 people seen in a 6-hour clinic.

Most of the clinic patients are self referrals. I also receive referrals of children who have failed a school/preschool hearing test or a tympanometry failure. Sometimes parents simply want their child checked for OME after a prolonged cold.

My greatest concern is for preschool and school children with OME that results in language/hearing problems. I am also concerned about those children with tympanic perforations with discharge that need "aural toileting or suction." (Aural toileting is another way of saying ear cleaning with salt water and tissue mopping and/or suction. No cotton buds allowed!) I seldom see people with acute problems, and if I do they are referred to a GP. For more serious complications like mastoiditis, I immediately refer the child to an otorhinolaryngological (ORL) specialist for hospital admission.

The hospital is located in Whangarei, about an hour or so of travel time from where I normally work. There are smaller hospitals in the area but none with an ORL available to assist.

Question: Does anyone work with you while you visit these communities?

Response: I have a Maori community worker who travels with me. As I have limited knowledge of the Maori language, it is important that the community worker can speak Maori. The community worker is the liaison with the children and their families. Often, while she is visiting families, I am on my own seeing people in the clinic. She is my link and support between a family that may not understand the relevance of regular ear checks for their children and families who have failed appointments to ORL specialists or to me. She works with the families to overcome these problems by assisting in handling such issues as the lack of transportation, working parent concerns, and any misunderstandings about the importance of attending the clinic. She does not have a clinical role. It is so important that she speaks Maori, especially when working with families in the Te Kohanga Reo preschool setting.

Question: Nursing roles and healthcare organizations vary from country to country. Do you believe your role as an "ear nurse" is unique to New Zealand?

Response: Our role does seem unique to New Zealand. There are about 34 nurses here who are ear nurse specialists. All ear nurse specialists use operating microscopes and suction equipment for aural toilets. Each ear nurse specialist is a skilled otoscopist. Each of these ear nurse specialists has completed a "hands-on" 3-year clinical training experience with peer audit. A peer audit is a clinical and portfolio assessment by a more experienced team of ear nurse specialists or an ORL specialist. The portfolio has current general competencies and general professional development updates in it and is usually submitted every 2-3 years.

Fundamentally, the ear nurse specialist's role is to diagnose, treat, refer, and monitor middle ear disease in children (some hospital nurses see adults as well). We all have a close working alliance with an ORL specialist and probably work at the level of advanced house surgeon, registrar level equivalent. (I believe this is equivalent to a US physician who has been out of medical school for about 2 years and is moving into a specialty practice.)

There are a wide variety of people who refer children to the ear nurse specialists, including allied health professionals, education professionals, and others. No one pays a dime as we are funded to treat children from birth to 18 year old from the Public Health budget. I am also paid from this budget. Any adults that I see by GP or practice nurse referral are treated the same way; however, if they need medication, they must go back to their referrer.

Question: What has been your most rewarding and/or demanding experience?

Response: The most rewarding experiences for me occur when I see parents recognize their child's symptoms and actively seek intervention. It takes time to develop a trusting, informed relationship with the families for this to happen. I probably spend the majority of my time doing individual client/family education around ears, hearing, and language development.

My most demanding cases involve the child who is deaf or failing to meet milestones and getting parents and/or families to recognize a problem exists, so they can decide on the treatment options.

Question: For a nurse considering a similar career or practice, what advice would you offer?

Response: A good understanding of ORL nursing is necessary. In addition, experience working with children and the ability to work autonomously are crucial. The interest and flexibility to work with different cultures are very important, as well as being prepared to work "outside the square" on most days.

For more information about the Ear Nurse Specialist Group, visit http://www.ensg.co.nz .
Questions and comments may be emailed to Marg Hunt at:
margaret.hunt@xtra.co.nz .

Map of Northland, New Zealand, Including Kerikeri
http://www.northernexposure.co.nz/map.htm

Driving Map of New Zealand
http://www.discover-new-zealand.co.uk/nz_map.htm

CIA - The World Factbook -- New Zealand
http://www.cia.gov/cia/publications/factbook/geos/nz.html

Kerikeri: Information and History
http://www.kerikeri.co.nz/Index.cfm

Kerikeri Photo Gallery
http://www.kerikeri.co.nz/PhotoGallery.cfm

Maps and Information About Northland New Zealand
http://www.rootsweb.com/~nzlwgw/nzlnorth/

Middleton B, Barrie T, King J. Ear nurse specialists: New Zealand's unique answer for the treatment of otitis media with effusion. "Glue Ear" International Congress Series. 2003;1254:501-506.
http://www.ensg.co.nz/PDF/ensg_oxford.pdf

ENT Nursing.com - Ear Infections, Hearing Aids, Inner Ear Infections
http://www.entnursing.com/index.htm

Society of Otorhinolaryngology and Head-Neck Nurses, Inc.
http://www.sohnnurse.com/

WISE EARS!
http://www.nidcd.nih.gov/health/wise/index.asp

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