Where are the Pacific nursing voices?

Former Cook Islands health secretary Elizabeth Iro (centre) received a ceremonial welcome home at the start of the 19th South Pacific Nurses Forum, where the NZNO delegation included (left to right) president Grant Brookes, Pacific Nurses Section chair ‘Eseta Finau, kaiwhakahaere Kerri Nuku and kaumātua Keelan Ransfield. 

The relationship that world health and nursing bodies have with the Pacific came under the spotlight at the South Pacific Nurses Forum.

By NZNO president Grant Brookes

Former Cook Islands health secretary Elizabeth Iro received a ceremonial welcome home at the start of the 19th South Pacific Nurses Forum (SPNF), held in the Cook Islands capital, Avarua, in October.

Her 2017 appointment to the re-established role of chief nursing officer at the World Health Organization (WHO) in Geneva, followed this year by the selection of Isabelle Skinner, of Australia, to head the International Council of Nurses (ICN), has brought the global institutions into closer contact with Pacific nursing.

The WHO, ICN and the International Confederation of Midwives (ICM) were all represented at the forum. Debates over their relationship with the Pacific arose from the outset.

These debates took centre stage during the half-day biennial general meeting (BGM) of SPNF member organisations, where NZNO was represented by kaiwhakahaere Kerri Nuku, Pacific Nurses Section chair ‘Eseta Finau and myself. They were also heard in the joint meeting with South Pacific chief nursing and midwifery officers which ended the 19th SPNF.

Nursing Now concerns

Concerns were already growing ahead of the forum over a proposed Pacific launch of the global Nursing Now campaign.Nursing Now is a three-year campaign to raise the status and profile of nursing. Although run in collaboration with ICN and WHO, it is a programme of the Burdett Trust for Nursing in the United Kingdom (UK), based on a report by members of the House of Lords and the House of Commons in London.

Some SPNF delegates felt there had been insufficient information and consultation with member organisations to allow them to endorse Nursing Now.

Others asked where the voices of the indigenous nurses of the Pacific were reflected in the campaign. For these reasons, NZNO decided to abstain from the launch.

The SPNF BGM later resolved to approach the board of Nursing Now to recommend that two indigenous representatives be appointed to the board.

Questions were also raised of the WHO, about why the nursing advisor role in their western Pacific regional office in Suva had been vacant since 2013. The joint meeting with chief nursing and midwifery officers agreed to write to the WHO South Pacific representative, seeking the re-establishment of this position.

The 19th SPNF concluded by expressing a willingness to restart joint work agreed at the previous forum in 2016, on opportunities to align regional regulatory frameworks for nurses and midwives across Pacific nations and on post-graduate education requirements in line with health workforce needs. •

(First published in Kai Tiaki Nursing New Zealand. Reposted with permission). 

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‘Helping across borders’


Helping across borders

Last month’s South Pacific Nurses Forum in the Cook Islands stressed the importance of cross-border health learning.

By NZNO president Grant Brookes

2 (crop)
NZNO representatives spend time with World Health Organization chief nursing officer Elizabeth Iro (centre). From left, NZNO president Grant Brookes, Pacific Nursing Section chair ‘Eseta Finau, kaiwhakahaere Kerri Nuku and kaumātua Keelan Ransfield. Photo/Abel Smith

“Our country borders should not be used as an excuse not to help each other.” With these words, Cook Islands Health Minister Vainetutai Rose Toki-Brown opened the 19th South Pacific Nurses Forum (SPNF), held in the capital, Avarua, last month.

The conference attracted about 300 participants, including official delegations from the 13 forum countries.

NZNO/Tōpūtanga Tapuhi Kaitiaki o Aotearoa was represented by kaiwhakahaere Kerri Nuku, chief executive Memo Musa, Pacific nursing section chair ‘Eseta Finau and president Grant Brookes, supported by kaumātua Keelan Ransfield.

Many others from New Zealand also participated – from academics to clinicians to leaders of nursing organisations. There were 45 presentations over four days on the theme, Transforming leadership – Nurses as change agents for non-communicable diseases (NCDs) in the Pacific. A strong focus was on the need for nurses to help each other across borders.

The South Pacific comprises nine of 10 countries in the world with the highest obesity rates, threatening a “tsunami” of NCDs across our region. The impacts of climate change were likewise highlighted as requiring regional collaboration.

We were reminded that the causes of these looming health crises also lie outside the borders of Pacific nations.

New Zealand’s and Australia’s multi-faceted role in the Pacific was showcased in a number of presentations. Since 2015, a mobile eye clinic, provided by the Fred Hollows Foundation, has delivered services to more than 23,000 people in Fiji, from nurse-led screening clinics to free spectacles, to cataract surgery and diabetic retinopathy laser treatment.

In the Kingdom of Tonga, support from Waitematā District Health Board (DHB) has enabled nurse leaders to develop and implement a culturally appropriate clinical governance framework.

Co-presenting with Janine Mohamed of the Congress of Aboriginal and Torres Strait Islander Nurses and Midwives, Nuku highlighted the role of Te Rūnanga o Aotearoa in creating an emerging alliance of indigenous nurses in the Pacific and beyond.

Maternal and child health

One day of the forum focused on midwifery and maternal and infant health. Vice-president of the International Confederation of Midwives (ICM) Mary Kirk spoke of ICM’s “twinning programme”, which pairs midwifery associations in high-income countries with those in low and middle-income countries (LMICs). “The benefits don’t flow only one way,” she said. “Both learn from each other.”

Presenters from LMIC island nations reported measures to tackle NCDs and other population health needs, measures that, in some cases, are more advanced than those in New Zealand.

A majority of Pacific countries have already introduced a tax on sugary drinks, while Tokelau has banned sugar-sweetened beverages altogether.

Strong nurse-led primary health care (PHC) and public health services in many Pacific countries have resulted in some higher health coverage indicators, eg vaccination rates, compared with New Zealand.

Presentations on nurse-led NCD clinics in the northern group of the Cook Islands (where there are no airfields and ships may visit once every four months), and in Tonga’s Vava’u group set the gold standard for universal health coverage and “leaving no-one behind”, no matter how remote.

A role delineation project in the Solomon Islands has mapped the country’s PHC services, nursing workforce distribution and workloads, utilisation rates down to clinic level, and current and projected population health needs. A national plan to improve health coverage and health equity, while at the same time balancing workloads and matching the nursing workforce to demand, has developed. New Zealand might benefit from developing such planning capacity.

The very idea of a border between New Zealand and the Pacific seemed to disappear altogether in some presentations. Manukau Institute of Technology senior academic lecturer Metua Daniel-Atutolu presented on a recent student placement in the Cook Islands. This aimed to strengthen students’ clinical and cultural competence to practise among Pacific communities in New Zealand.

Auckland parish community nurse (PCN) Loli Channing described how her role fits with the “healthy village action zone” model of care. This model was developed to align with the values of Pacific peoples in New Zealand. She encouraged conference participants to explore the role of the PCN in their own Pacific nations.

Auckland District Health Board clinical nurse specialist in HIV Sonya Apa Temata presented an approach to health and well-being based on Cook Islands indigenous epistemologies, developed in Aotearoa.

The four days of the forum demonstrated the truth of a quote from the ICM vice-president’s talk, which we would do well to remember: “If I go alone, I may go faster. But if we go together, we will go further.” •

(First published in Kai Tiaki Nursing New Zealand, November 2018. Reposted with permission. Additional coverage held over to the December issue).

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‘Where are the Pacific nursing voices?’

Walking together in solidarity and friendship

BEING IN Suva for three days attending the FNA symposium and AGM highlighted for me and kaiwhakahaere Kerri Nuku the strong ties between nurses in the two countries. The visit also enabled shared learning.

NZ team at FNA
“Team New Zealand”: Symposium participants from Aotearoa pictured with FNA President Dr Adi Alisi Vudiniabola (second from right).

Auckland-based Pacific nursing leader Fuimaono Karl Pulotu-Enderman opened the symposium as the first keynote speaker. The closing speaker was Abel Smith, a former member of the FNA executive who now holds many nursing leadership roles in New Zealand. He is treasurer of NZNO’s Pacific nursing section.

In between, there were presentations from Auckland University researcher Ofa Dewes, from Waitematâ District Health Board’s health science academies programme coordinator Malcolm Andrews, and from two other New Zealand-based nurses, Simione Tagicakbau and Vunirewa Uluilakeba.

It was the first time that elected NZNO leaders had been invited to open the AGM. Participation as FNA’s chief guests was a great honour. The experience showed me the many similarities between our two countries, but also some differences.

Fiji – Grant & Kerri
NZNO co-leaders at the FNA AGM.

NZNO can only aspire to the kind of relationship with the Ministry of Health that exists between the FNA and the Fijian Ministry of Health and Medical Services. The chief nursing and midwifery officer, Silina Waqa-Ledua, responded on behalf of the ministry to many questions and comments from delegates.

“There are many commonalities,” Nuku said. “Fijian nurses are also grappling with health underfunding, the growing burden of non-communicable diseases, poverty, climate change and the dangers of privatisation.

“But only more recently have they begun to seriously consider cultural safety, in the context of increasing numbers of internationally qualified nurses being employed in foreign-owned private hospitals,” she said.

Around 300 nurses attended the events, over the three days. My opening address to the AGM, ‘Walking together in solidarity and Pacific friendship’, is available online: https://nznogrant.org/2018/04/29/walking-together-in-solidarity-pacific-friendship-speech-to-fijian-nursing-association-agm/ 

Report by NZNO president Grant Brookes

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Pay push for Fiji nurses




Pay push for Fiji nurses

With the backing of NZNO and an Australian nursing and midwifery union, Fiji nurses have achieved significant pay increases.

By NZNO president Grant Brookes

In April, kaiwhakahaere Kerri Nuku and I were invited as honoured guests to open the Fiji Nursing Association (FNA) annual general meeting (AGM). The invitation for the NZNO co- leaders to attend came after joint work last year between FNA, NZNO and the New South Wales Nurses and Midwives Association on a pay push for Fijian nurses.

It was the latest in a long series of collaborations between the Pacific nursing unions. In 2005, after New Zealand’s “fair pay” multi-employer collective agreement was successfully concluded, NZNO campaign leaders travelled to Fiji to support the FNA’s own fair pay campaign. In return, FNA leaders shared their victory and inspired delegates at the following NZNO AGM.

More recently, Fiji’s nurses had seen their pay fall behind the rising costs of living. But in 2017, backed by Australasian research and policy analysis, the successful FNA submission on a new civil service salary structure has resulted in pay increases of up to 75 per cent.

For the first time, the new pay grades recognise advanced nursing practice and specialty roles. However, they also impose five-year fixed term contracts in place of previous permanent employment.

The first roles to be graded under the new salary structure include nurse practitioners (NPs) and midwives. NP Vilisi Uluinaceva told me that the FNA’s evidence-based submission made a big difference.

Vikatoria & Vilisi IMG_6922
Nurse practitioners Vikitoria Makrava (left) and Vilisi Uluinaceva enjoy a break during the AGM.

Previously, she said, Fiji’s 40 NPs earned between FJ$26,000-28,000 (NZ$19,000-20,400) a year. “We’d been working for so long on that pay, we didn’t know how to bring this up.”

Now, she said, they’re on FJ$43,000.

Fellow NP Vikatoria Makrava explained: “When we talk about pay, we look at what we do. Many of us work in remote areas. There are no doctors. We prescribe – we do everything – and we might see more than 60 patients in a shift. The pay was not appropriate before.”

Aliote Galuvakadua is a midwife and maternity unit manager who first registered as a nurse in 1976. She said she was excited when she read the FNA submission. It has seen midwife pay go from FJ$18,000 to FJ$28,000.

Fiji Times photo (with Aliote Galuvakadua)
Midwife Aliote Galuvakadua explains what the new civil service salary structure means for her profession at the AGM (Photo/Fiji Times).

“The paper was really good”, she said. “It’s good we have been recognised as specialists after all these years. Talk of balloting for a strike is now gone.”

Other nursing specialties have either undergone, or are about to undergo job evaluations in order to be placed on the new salary scale. So far, the average pay increase for the nation’s 3360 nurses has been 14 per cent.

Meanwhile the Fiji Trades Union congress has lodged a dispute with the Ministry of Labour over the decision to place all civil servants on individual fixed-term contracts and says it plans to take the matter to the International Labour Organisation. •

First published in Kai Tiaki Nursing New Zealand, June 2018

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Boosting Pacific representation at ICN

KT photo July 2017
Some of the New Zealand nurses who attended the ICN congress in Barcelona flank ICN chief executive Frances Hughes (centre right, in white) and NZ’s chief nursing officer Jane O’Malley (centre left). NZNO president Grant Brookes is on the far left and chief executive Memo Musa is third from left.

NZNO successfully promoted better representation for Pacific nations at ICN.

By NZNO president Grant Brookes

Last month, NZNO chief executive Memo Musa, kaiwhakahaere Kerri Nuku and I travelled to Barcelona for a series of meetings held under the auspices of the International Council of Nurses (ICN).

From May 27–June 1 we took part in the 2017 ICN Congress, along with close to 20 other New Zealand nurses. For the three days prior, we represented New Zealand nursing at the ICN Council of National Representatives (CNR).

Founded in 1899, ICN articulates the voice of nursing to the World Health Organization and other global institutions. NZNO has been a member since 1912.

CNR is ICN’s biennial decision-making forum. There, the 135 member organisations from 133 countries are able to debate and vote on the way forward.

Unlike previous meetings, there were no other national nursing associations (NNAs) from the South Pacific attending. So it was up to NZNO, along with the Australian College of Nursing and the Australian Nursing and Midwifery Federation, to bring a Pacific nursing voice to the world stage.

Among the votes at CNR was an election to fill four vacancies on ICN’s 14-member governing board.

ICN elections are conducted regionally. New Zealand is part of area seven, which covers the Asia-Pacific region. Nuku was standing for election to the single vacant seat on the board for this area.

But the smaller countries of the Pacific have long struggled to get our nursing voice heard at the top table. Area seven board members are usually elected from the large NNAs of North Asia. In Barcelona, the seat was won by Wu Ying, the candidate from China.

So, when a separate vote on redrawing the boundaries of the voting areas to match those of the World Health Organization, placing New Zealand in a new Western Pacific Region, NZNO moved an amendment to create a South Pacific sub-region within that.

“There is a large group of NNAs from the South Pacific who share commonalities of language, culture, nursing education, regulatory and legal frameworks and health system organisation. And yet this large group of NNAs has been largely excluded from representation,” I said, when introducing the motion. It was seconded by the Australian College of Nursing.

In 2016, the ICN board and president had considered the possibility of establishing sub-regions, but decided against. With support from Australia, CNR voted by a margin of three to one to overturn that decision and support NZNO’s amendment.

CNR also heard an update from ICN chief executive Frances Hughes about her transformation agenda, aimed at modernising the 118 -year-old organisation.

Plans include decentralising ICN away from its Geneva headquarters to provide a greater regional presence, revamping ICN’s communications and digital services (including a new international platform for online professional development) and stronger governance and financial management.

NZNO has expressed concerns over recent years about ICN governance and financial sustainability. In Barcelona, Musa was unexpectedly invited to present a training session on good governance to the incoming ICN board, under newly-elected president Annette Kennedy.

As part of its push to decentralise, ICN wants expressions of interest in hosting a series of regional forums from 2018. At last year’s NZNO annual general meeting, delegates, by a show of hands, expressed support for hosting such a forum in New Zealand. NZNO is now in the early stages of planning a possible ICN forum. •

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First published in Kai Tiaki Nursing New Zealand, July 2017. Reposted with permission.


Atoifi Hospital leads the research agenda

SITUATED ON the east coast of Malaita Island, the Atoifi Adventist Hospital was established in 1966 by the Seventh Day Adventist Church. Now celebrating its 50th anniversary, the hospital has grown to include an extensive primary health-care service to remote villages. The attached college of nursing has become an official campus of Pacific Adventist University (PAU).

In the beginning, the Atoifi clinical staff struggled to deliver culturally safe care. The East Kwaio people, who the hospital serves, include some mountain tribes who have not converted to Christianity and who maintain traditional beliefs and customs. However, in recent years a new crop of hospital leaders have forged deep relationships with community leaders and tribal chiefs.

An effort to have local evidence inform local practice was a driving force behind improving cultural safety. In 2008, Atoifi Hospital invited public health academics at James Cook University (JCU) in Australia to help build research activities for hospital and college of nursing staff. From there, the Atoifi Health Research Group (AHRG) was born. Today, its academic partners also include the PAU in Papua New Guinea, CQUniversity in Queensland and the London School of Hygiene and Tropical Medicine.

NZNO president Grant Brookes with traditional medicines researcher Tommy Esau.

Ten members from AHRG presented a series of papers at the forum. Director of nursing and adjunct lecturer in the school of public health, tropical medicine and rehabilitation sciences at JCU Rowena Asugeni presented on how community efforts prompted the establishment of a culturally safe tuberculosis (TB) ward. Malaita Province has the highest incidence of TB in the Solomons, but Atoifi Hospital staff had noticed a problem of patients self-discharging before finishing their treatment.

Through research-based interviews, Asugeni found, in the words of one participant: “Last time hospital keepim olketa (mountain people) just next to the place wea olketa women give birth lo olketa pikinini yia. Lo culture blo Kwaio, dat wan hem very, very, very taboo something nao yia.” (In the past, hospital kept mountain people next to the place where women gave birth. In Kwaio culture, this situ- ation is absolutely forbidden.)

As a result of her research, the TB ward was re-designed and re-built to be culturally ap- propriate for Kwaio people.

A lecturer at PAU and adjunct lecturer at JCU, Humpless Harrington, presented the AHRG’s research model. He described the first research capacity strengthening workshop run by JCU academics at Atoifi. There were over 100 attendees, including village leaders, ministers and tribal elders. Despite sessions being conducted in both Pijin and English, concepts such as “naturalistic”,  “induction”, “empirical”, “positivistic”, were barriers for some of the people. They asked the JCU academics to come back for longer periods and use a practical “learn by doing” approach, so they did.

Humpress also presented a paper on eliminating soil-transmitted helminths. He said he had trouble getting his research published because the findings, that public health measures to eliminate these parasites on Malaita should be implemented village by village, were not in line with World Health Organisation (WHO) protocols.

“But that’s why you do research – to test prevailing wisdom,” Harrington said. Following the WHO protocols in the local context would have resulted in an over-use of drugs, rather than finding a local solution, he said.

AHRG researcher Tommy Esau presented on the “Kwaio traditional medicines handbook: customary treatment of head lice with the falange tree”. The medicines handbook has documented medicinal properties and tradi- tional uses of 15 plants found on Malaita.

Since 2009, research outputs from AHRG staff have included 15 papers published in a range of peer-reviewed international journals.

Today, the health service receives some government funding, but continues to rely on church support, foreign donors and local fundraising. More information can be found at www.atoifiresearch.org.sb. •


Solomon Islands face health challenges

THE SOLOMON ISLANDS are made up of nine culturally diverse provinces, each home to many wantok (tribal) groups and languages. It is situated northeast of Australia and just south of the Equator.

In his opening address, Solomons Prime Minister Manasseh Sogovare said that life expectancy in the country of 600,000 people had not increased since 2000, despite health spending making up 15 per cent of his government’s budget. The year 2000 also marked a turning point in the country’s history, when armed militants overthrew the government of Prime Minister Ulufu’alu. A five-year period of conflict was brought to an end in 2003, with military intervention led by Australian and New Zealand, but stability and development had not yet been fully achieved, Sogovare said.

Development issues are evident in the country’s relatively high infant, under-five and maternal death rates. More than 45 per cent of the population is under the age of 15. Efforts to address these issues featured prominently in one of the two streams in the forum’s concurrent sessions.

Less than 60 per cent of Solomon Islanders enter secondary school and fewer than five per cent finish Year 12, which is a requirement to enter a bachelor of nursing programme. Despite the challenges, the Solomon Islands has much to offer other NNAs in the South Pacific.

Decisions at AGM

The SPNF annual general meeting was held on the final day. This saw the adoption of a revised constitution, with the Cook Islands nursing association confirmed as the SPNF host in 2018. The steering committee is to prepare a draft five-year strategic plan. It was agreed the South Pacific Chief Nursing and Midwifery Officers Alliance would work with SPNF to align regional regulatory frameworks and postgraduate education requirements. *The SPNF communiqué can be found at: www.spnf.org.au/2016_General_Meeting/SPNF_Ho- niara_NNA_Communique_V2.pdf.

(First published in Kai Tiaki Nursing New Zealand, December 2016. Reposted with permission.)

Pacific nursing excellence

Culturally safe nursing care, the challenges of climate change and developing an indigenous nursing voice were some of the themes to emerge from the 18th biennial South Pacific Nurses’ Forum in the Solomon Islands.


Some of the New Zealand delegates. From left: NZNO kaumātua Keelan Ransfield, Nursing Council board members To’a Fereti and Catherine Byrne, and chief executive Carolyn Reed, Pacific Nursing Section chair ‘Eseta Finau, NZNO kaiwhakahaere Kerri Nuku, president of Te Kaunihera o Ngā Neehi Māori Hemaima Hughes, NZNO chief executive Memo Musa and president Grant Brookes, and member of NZNO’s Greater Wellington Regional Council Jenny Kendall.

By president Grant Brookes

For the first time in its 34-year history, the South Pacific Nurses’ Forum (SPNF) was held in the Solomon Islands. More than 300 people gathered in the capital Honiara for five days at the end of October/early November – nurses and midwives, regulators, health sector leaders and representatives of national nurses’ associations (NNAs) from 10 Pacific nations.

The NZNO delegation comprised kaumātua Keelan Ransfield, Pacific nursing section chair ‘Eseta Finau, chief executive (CE) Memo Musa, kaiwhakahere Kerri Nuku and president Grant Brookes. There were eight others from New Zealand too.

Speakers addressed the theme “Towards nursing excellence for universal (Pacific) health” in plenary and concurrent sessions over the first four days, with cultural performances in the evenings. On the final day, NNAs and chief nursing and midwifery officers made a  series of decisions, including the need to transform nursing education, charting the way forward in the South Pacific over the next two years. From the opening address by Prime Minister Manasseh Sogovare, the health and social challenges facing the Solomons – as well as world-leading initiatives in culturally safe health-care emerging in the country – featured prominently. These included challenges posed by climate change.

It was also the first time the president of the International Council of Nurses (ICN) Judith Shamian had attended the SPNF. She spoke about ICN’s role in shaping global health and development strategies, including work towards universal health coverage by 2030, as mandated by the World Health Organization and the United Nations’ sustainable develop- ment goals. In her keynote address and in a later meeting with NNA representatives, Shamian encouraged stronger participation in ICN by South Pacific nurses.

This issue was taken up in a joint presentation by Nuku and Finau, Voice for the Pacific. Finau pointed out that ICN Region 7 comprised NNAs from Asia and the Pacific. “But at ICN, our issues are not discussed. We need to be at decision-making tables.”

This was why Nuku was standing for election to the ICN board next year. “This is the time when we Pacific nurses need to stand together,” said Finau. “Within our region, the SPNF should be driven by the NNAs. But the last two forums have been driven by the chief nurses.”

In a separate presentation, Building a resilient indigenous workforce, Nuku expanded on the theme of having a specific indigenous voice within Pacific nursing.

This subject was also addressed by Congress of Aboriginal and Torres Strait Islander Nurses and Midwives (CATSINaM) CE Janine Mohamed.

She spoke of the deepening collaboration between CATSINaM and Te Rūnanga o Aotearoa NZNO. The idea of global connectedness grew “from this great dialogue of support and commonality”, she said. CATSINaM is now proposing a global alliance of indigenous nurses and midwives.

Although acknowledging that “indigenous” means different things in different countries, the NNA representatives who met on the final day approved changes to the SPNF constitution which would allow groups like CATSINaM to apply for full membership of the forum.

In a presentation titled Pacific nursing excellence – cultural democracy is choice, Finau stressed the need for health equity, freedom to practise culture without discrimination and ethnic-specific services. “If you have Tongans talking to Tongans, the information will go further.”

Finau was one of several speakers who compared some foreign health advisers and aid partners to “mosquitos”. “They fly in, then fly out,” she said, “without ensuring succession planning, so there is someone to take over. They don’t focus on ethnic-specific services, but on other things like ‘economies of scale’.”

Stand-out presentations on culturally safe health-care for one specific ethnic group in the Solomons came from members of the Atoifi Health Research Group (see article below).

The final theme running through the conference was climate change. Presenters included Solomon Islands nurse Alison Ripiapu Sio, Cook Islands emergency department nurse Nga Manea and mental health instructor from Atoifi Adventist Hospital James Asugeni. Speaking on current and likely mental health issues from rising sea levels in a remote coastal region of the Solomon Islands, Asugeni said the main city on Choiseul Island was set to become the first provincial capital in the world forced to relocate due to climate change.

His research focused on six villages nearby, where rising seas are inundating houses and places where families and communities gather. He found mental health issues affected all the survey participants.

NNA leaders agreed to prioritise action on the causes and health effects of climate change in our closing communiqué (more information on page 13*). •

(First published in Kai Tiaki Nursing New Zealand, December 2016. Reposted with permission).