From 'useful wife' to NP professor: Massey nursing leader is never far from child-health front line

In 1989, when Karen Hoare accompanied her paediatrician husband to The Gambia, it was as a “useful wife”. “That made me laugh…it was so 1980s,” recalls Professor Hoare, who was an experienced nurse and a mum of a baby and a toddler at the time.

The “useful” part of the paternalistic job description turned out to be apt. The professor-in-the-making proved very useful indeed to the community the West African field station served.

During her two years in The Gambia, she also started building the assessment and research skills that pushed her along the path to becoming New Zealand’s first practising nurse practitioner who is also a professor.

The Massey University director of postgraduate nursing was promoted to full professor late last year.

Professor Hoare, a practising partner in Manurewa’s Greenstone Family Clinic, south Auckland, has a research focus on children and young people.

Born and bred in a village near Coventry, England, by the age of 12 she was thinking about nursing and child health.

She discovered a preschooler cousin had been diagnosed with a brain tumour. “It was quite profound, the dramatic effect being in hospital had on her, and the way she tried to work through it was play,” says Professor Hoare.

“So as a 12-year-old I played hospitals a lot with this little three-year-old.” After deciding to swap play for real, she trained as a nurse at Great Ormond Street Hospital in London.

On graduating in 1978, she worked in a child oncology ward with top oncologists who were working on acute lymphoblastic leukaemia treatments.

She went on to undertake the one-year training to become a health visitor, a specialist community public health nurse scope unique to the UK.

She registered as a health visitor in 1985, the same year marrying paediatrician Simon Hoare. By the time the couple headed four years later to The Gambia, they had a two-and-ahalf year old and an eight-month-old.

“I was very much a mum,” Professor Hoare says. As a health visitor, she was still a novice. The Gambia research field station where she and Dr Hoare worked had never had a health visitor but she was soon put to use.

“In the wet season, there would be a deluge of really sick children in the clinics that Simon was having to run,” she says. “And he was the only doctor to start with, so he said to me ‘you are a children’s nurse, you could do some of this’.”

He started teaching her advanced assessment skills so she could run her own clinics, laying the foundation for her later NP role.

Her research career also had its origins in her time in The Gambia, triggered by the tragic death of a nine-month-old baby due to a mother not understanding the importance of oral rehydration salts in treating diarrhoeal disease.

The lack of health literacy in the village prompted Professor Hoare to start an eight-week rolling health education programme to mothers on handwashing, immunisations, common childhood diseases and family planning. She ran a quasi-experiment to monitor the impact and, in a followup visit in 1997, found her one-off intervention was still causing an ongoing “huge reduction” in hygiene-related childhood infections.

Professor Hoare feels the fact she was a mum of young children contributed greatly to the success of the intervention.

As well, she learned to speak the local language, Madinka, and worked with “four fantastic women” from the local community.

When she visited the village again in the early 2000s, she found women still singing the songs they had written to remember and share “Kareni’s” teachings. “That was really profound,” she says.

The charitable organisation she founded – Development Direct – aims to help build awareness of development issues through children. It links schools in north-east England, where she lived at the time, with schools in Africa and South America around working on a local health project. She remains a director and is closely linked to the organisation.

You know how nurses have to fight to become prescribers here? In the UK, I had to fight to get them to prescribe

Professor Hoare had resumed her health visitor career on the family’s return in 1991 to the UK, where they had their third child, and enrolled in a masters programme.

In the late 1990s, she found herself caught up in a nurse prescribing and primary care revolution spearheaded by Tony Blair’s New Labour government. In the space of a year, she became a nurse prescriber and an executive nurse on the board of one of the newly created primary care groups, the Central Northumberland Primary Care Group, created with the aim of shifting power from secondary to primary care.

“My role was to encourage something like 150 health visitors and district nurses in our local primary care group to become prescribers.

“You know how nurses have to fight to become prescribers here? [There,] I had to fight to get them to prescribe,” she says.

The family moved to New Zealand in 2003, the year our first prescribing NP was authorised – she felt the need to respond to a New Zealand Medical Journal editorial that waxed sceptically of nurse prescribing. Professor Hoare pointed out it was already old hat in the UK.

It was frustrating at first trying to fit her UK health visitor scope and advanced practice experience into a New Zealand public health nurse role.

She eventually found her niche after taking up an academic nurse job at the University of Auckland, meeting specialist GPs and primary care academics Bruce Arroll and Tana Fishman in late 2006. The pair had founded the Greenstone general practice that same year and persuaded her in mid-2007 to start a Saturday morning clinic, “basically case-managing populations of pregnant women and children”.

The GPs also felt it was a good idea for her to become an NP, which she achieved in 2009 with Professor Arroll as her prescribing mentor. He is now the patron of Nurse Practitioners New Zealand and an advocate of the NP role.

Ever since, Professor Hoare has continued to run two half-day clinics for Greenstone, usually focused on children, young people, and mothers and babies, alongside academic jobs. Since 2017, she has been based at Massey University.

One of her early initiatives at Greenstone was the ongoing “Best for Baby” programme to better coordinate mother and baby care, from confirmation of pregnancy to enrolling and immunising the newborn. This includes arranging midwifery care, offering mums a pertussis and flu vaccination, recording their midwife’s details and estimated delivery date in the practice management system, and inviting women in their third trimester for a free visit to the practice, where they are gifted a Best for Baby kete of goodies. The scheme has improved immunisation rates for infants and maternal pertussis immunisation rates, says Professor Hoare.

The practice also worked closely with school nurses in secondary schools across south Auckland, including on the “teabag” sexual health promotion.

Nurses at one high school had discovered in 2011 that 12 girls had become pregnant over the summer break, leading to a group of student nurses designing a sexual health leaflet that folded into a teabag-shaped envelope holding a condom.

The envelope is handed out to older teenagers at the end of term and promotes free sexual health clinics at Greenstone while schools are closed.

Data demonstrate that the intervention (no longer funded) reduced teenage pregnancies.

In 2010 Professor Hoare was invited to become a financial partner in Greenstone, one of the first NPs around the country to buy into a general practice.

“It’s really good, as it means I have a say,” she says. She saw the potential for Greenstone to also train new graduate nurses and now notes proudly that the practice has trained 14 new graduate nurses and four NPs.

Working with the “digital native” generation of nurses spurred her PhD thesis, completed in 2012. She found the older practice nurses teach the new graduates clinical skills, communication skills and knowledge about the local community. “And the new graduate nurses are amazing in terms of being able to educate the whole team about accessing up-to-date best practice information, as they’ve got the technical savvy.”

Since 2017 she has led the NP final-year programme at Massey. With more than 625 NPs now actively practising in the country, and 80 NP trainees signed up this year to the expanded Nurse Practitioner Training Programme (NPTP), she says she feels very positive about the NP role’s future.

More younger people are coming through programmes and an NPTP focus is to boost the “woeful” low number of Māori and Pacific NPs.

“And nurse practitioners are the clinical leaders of nursing in this country. This is what we are teaching them. You are not just becoming people who can diagnose and prescribe. You are becoming leaders who will change the way that we deliver health services.”

She sees NPs being advocates for patients and for addressing health inequities faced by Māori and Pacific peoples, and especially children.

Advocacy for change is among the jobs she will pass to the next generation as she starts looking towards retirement after 45-plus years of nursing. She, like many, has found the past few years, particularly last year, much more demanding.

“I found it tough because I got COVID last May with query cardiomyopathy. I took a long time to recover.”

She got a clean bill of health in September but then got RSV from a coughing child.

“So, personally, last year wasn’t good…but it ended on a very high note because my daughter got married and that was lovely.”

With an international family (she has one son in Germany and another in Australia’s Whitsunday Islands) and a twoyear-old granddaughter, more time with her own family beckons. But she’s not ready to give up being useful just yet. “We like what we do,” she says.