Rural Nurses: Knowledge and Skills Required by to Meet the Challenges of a Changing Work Environment in the 21st Century: A Review of the Literature

Introduction
Current education providers
Educational philosophies and modes of delivery
Mentorship and Preceptorship
Pre-registration education
Post-registration education, professional development
Clinical
Education
Management
Generic

Continuing learning skills

Introduction

"Access to timely and appropriate education, training and professional support is essential for any health professional" (Handley 1998,p.17). Consistently it is reported in the literature that rural nurses are disadvantaged in accessing education and training (Hegney et al 1997; Kreger 1991). One of the reasons identified that limits the access to educational programs is the financial cost. These costs include course, travel, accommodation, childcare, and for the employee back fill or locum relief. If rural nurses are to be encouraged to undertake educational programs financial support such as scholarship programs and employer support must be considered as essential.

Continuing education is of the utmost importance to rural nurses in Australia. The presence of continuing learning opportunities has been found to enhance the self-esteem, aid networking and promote personal and professional development of those who take part (Anderson & Kimber: 1991). Alternatively lack of learning opportunities can deter nurses from practicing rurally. Huntley (1995) found that 71% of rural nurses surveyed stated that the "lack" access to continuing education opportunities could contribute to them leaving their rural nursing position. Huntley identifies the provision of continuing education for rural nurses as one of the top priorities of rural Universities. Lack of access to continuing education opportunities was seen to be a major human resource issue in Victoria (Victorian Hospitals Association: 1992). Buckley and Gray (1993) also demonstrated the importance that rural nurses place on continuing education in a study in which they asked rural and remote nurses to rate the personal importance of various educational activities. They found that highest rating activity was continuing education (65.3%) followed by employer support for study (64.7%). They conclude that the provision of continuing education and employer support are key issues for rural nurses.

With the importance of continuing education for rural nurses clearly identified it would be hoped that the literature would provide us with a very positive picture of learning opportunities for nurses working rurally - however this is not the case. Blue and Howe-Adams (1993) note that those who want to pursue professional education face a daunting task from three perspectives: choosing a suitable education program, accessing the program and finally staying with the program.

The provision of education and training for nurses in rural Australia suggests the Association for Australian Rural Nurses fail to meet the needs of its membership. AARN (2001,p.2) suggests the following reasons;

Postgraduate education is too onerous, inaccessible and expensive and there is little reward in the workplace for the qualifications gained
Many new graduates are unable to cope with the pressures of the workplace and quickly leave, pursue other positions or leave the profession
Many new graduates who go to rural areas do so with inadequate specific preparation for the rural context
Poor support for Postgraduate rural students from some Universities results in the student receiving a poor learning experience, and demonstrates inadequate support for external students (needs clarification - a good point but needs more)
Appropriate education for managers, specialists, nurse practitioners and those working outside traditional hospital roles needs urgent review.

AARN (2001) further assert that most educational programs available for specialist education and training, involve on-campus residential periods, which make access for many rural nurses impossible. It may therefore be necessary to rethink the delivery of clinically based courses, and include more flexible (and affordable) options for how students gain clinical skills.

In her literature review Handley (1996,p.7) identifies two main problems with the training and education of rural nurses:

There is an inadequate or inappropriate tertiary education for rural practice at the pre-registration level, often combined with a lack of preparatory training for registered urban nurses moving to rural positions."
"Once employed in a rural position, whether hospital trained or tertiary trained, nurses can have difficulty in maintaining professional competences through continuing education or further degrees, and in developing new specialist skills.

The role of education providers with regard to rural nursing is complex. Hegney et al (1997) have identified the roles of the education providers for rural nurses as being:

Preserving the focus on nursing as a unique discipline within the mutlidisciplinary team
Keeping abreast of and supporting professional change such as that heralded by the advent of advanced nurse practitioner role
Providing educational programs necessary for developing and maintaining rural nurse competences
Working towards cost effective, accessible, equitable and streamlined educational programs
Providing a forum for sharing education and peer support for isolated nurses
Recognising and creating curricula on the basis of preparing nurses for the specialty role of the rural nurse.

Spencer et al (1998) have identified key responsibilities of educational providers. Combined with Hegney's roles these provide a valuable check list by which educational providers judge their performance in this area and a guide to those developing initiatives to encourage continuing education opportunities for nurses in rural Australia. The responsibilities identified are:

Encouraging and facilitating the uptake of courses

Education providers should ensure multiple entry points and recognition of prior learning
Education providers should accept students with cross-industrial credits and encourage articulation between different forms of continuing education
Education providers should increase access to education using a range of delivery styles, including innovative use of information technology
Education providers should work to ensure flexible time-tabling, both in when and how courses are taught and flexibility in date dues for assignments, recognising the limits of rural postal services and pressures of work
Education providers should aim for accreditation of all courses
Education providers should ensure teaching provides access to both knowledge and experience through appropriate placements
Education providers should actively circulate information about their courses
Education providers must recognise that the scope of practice of rural nurses is different to that of city/urban nurses and their education needs may also differ.

Identifying and responding to local and regional needs;

Providers of education and training for rural nurses must recognise the widely varying local and regional needs of those nurses
Education providers must accommodate current and changing learning needs in the light of an increasing emphasis on competencies, credentialing and advanced practice

Working collaboratively to foster a culture of learning;

Education providers must foster a culture of learning that encompasses all members of the learning circle, including rural nurses, their managers, and educational providers.

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Current education providers

There is presently a range of education providers offering opportunities for nurses working in rural Australia. Spencer et al (1998) have identified the providers of education and training and support organisations for rural nurses include universities, federal and state health departments, Rural Health Training Units, Hospitals and Private groups. There are also organisations that have developed to support rural nurses including the association for Australian Rural Nurses Inc (AARN), the National Rural Health Alliance (NRHA) and the National Association for rural Health Training Units. There is a commercial organisation Pathways Nursing Education Service. There are also information services such as the Health Education Rural and Remote Resources Database (HERRD), Nursinginfo (Flinders University) and the Rural Information Network (Toowoomba Rural Health Training Unit). Since 1993 and 1996 there have been major initiatives to address the problems faced by nurses who want to undertake further study. Many Australia Universities offer continuing learning opportunities for Rural nurses and in1997 the Commonwealth funded University Departments of rural Health. Spencer et al (1998) state that these play a significant part in supporting nurses in education but warn that programs offered have had varying degrees of success.

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Educational philosophies and modes of delivery

The practice of nursing is fast changing. The knowledge base and skills developed by nurses during their education begins to become out dated on their first day in clinical practice. This has been recognised by most education establishments and they have endeavoured to give their students learning skills that they can use during their entire professional life. However, it should be noted that life long learning is more than a simple set of study skills. The notion of life long learning leads comfortably into the development of a culture of learning, that is, accepting the attitude that learning, along with the tools of support to achieve the learning, is an accepted part of one's working life. It is this culture that provides the ways, means and the incentives for learning. Various theories of education need to be employed to underpin curriculum development (Landa et al 1995, Marland and Store 1982, Rowntree 1990, Gross-Davis 1993). Like any culture, this one offers a wide provider and employer resources. Flexibility in education and training, recognition of experiences and prior learning, acceptance of different learning styles and respect for individual needs, commitments and resources are all components in such a culture suggest Spencer et al (1998).

Providing continuing education in rural Australia is very different to providing it in Metropolitan areas. The reduced density of students means that provision of services and delivery methods have to be carefully considered. Because of the distances that rural nurses live from education provider's modes of delivery such as internet and distance education are often tried. However it is found that rural nurses prefer more traditional forms of delivery such as face to face education (Blue 1993; Buckley & Gray 1993; Sturmey & Edwards 1991). This was reflected in Huntley's (1995) survey that found that rural nurses ranked technological approaches to education as important rather than very important.

Although distance education may be seen as a major tool for delivering education to rural nurses it does have its limitations. It has difficulties of providing "Hands On" clinical skills (Spencers et al 1998). These are the very skills that many rural nurses are seeking. Some centres address this issue by using information technology such as multi-media and CD ROM - however, high costs of information technology equipment may reduce the availability to rural nurses (Project for Rural Health Communications and Information Technology 1996).

The most popular learning styles for rural nurses undertaking postgraduate course are (Sturmey & Edwards 1991);

face to face discussion and skill development
observing and working with previous workers to 'learn the ropes'
observing and being supervised by experienced workers early in employment

The same study found that the most unpopular styles were:

distance education to be completed while in the field
computer assisted learning packages
radio lectures

Chapter Continuing Learning Skills continues

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