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
Health funding
The provision of health services in rural areas of Australia is complex in that the problems of distance and sparsely populated areas have yet to be overcome (Hegney and Hobbs 1998). It is also recognised that the health services are inadequately funded (Department of Community Services and Health 1991, Fragar et al 1997). Hegney (1996) argues that historically health service provision in rural areas has been ad hoc. Moreover Hegney and Hobbs maintain that Health Policies in Australia are characterised as:
- Being fragmented, and reflecting the division of responsibilities between Commonwealth, State and Territory governments;
- Emphasising institutional care rather than health promotion and prevention; and
- Being based upon cost containment and minimisation, efficiency and cost effectiveness rather than ensuring the effectiveness of the services provided (1998, p4).
McMurray (1999,p.341) asserts that "... among the health systems of the world, there is no paragon of excellence". What is central however, is an underlying assumption that the system will be responsive to the needs of the nation and that the system must be funded. She concludes that governments have finite resources and the distribution of funds must be devolved to address the health concerns of the nation. Wass (2000) points out that while Australia agrees with the rhetoric of the World Health Organisation relating to equity, she suggests that the health care system is driven by a medical model which does little to address inequities and does not empower the community. Hegney and Hobbs (1998) maintain that the "... rationalisation of health resources has led to demoralisation and de-skilling of health professionals as health services are closed or down sized" (p4).
As well as having an impact on the rural nurse's work environment, financial issues also have a direct impact on the provision of education to rural nurses. In the previous section the importance of access to education was high lighted. However there are limits to funding for rural health care. This can manifest itself as a lack of support for clinical education and staff development. A study of Victorian rural district nurses found that management and community expected resources to be directed towards service delivery rather than staff development (Progressive Projects Lampshire and Rolfe: 1993). NSW nurses also feel that budget constraints make course attendance difficult (Donnelly: 1992).
Health care funding has a direct impact on the work and education of rural nurses. It is therefore important that they have a sound knowledge and understanding of the politico-economics of health. Rural nurses have a significant role in lobbying health authorities and other agencies for funding to support health services (Bushy 2000). Furthermore, nurses are increasingly being asked to justify their practice within budgetary constraints, and are required to develop applications for funding and identify sources for financial support outside traditional income avenues. Understanding the processes associated with such applications, policy and funding mechanisms are core skills for nurses in the 21st Century. Educational programs should provide content to assist nurses develop these skills and providers of professional development should also address these issues with regular updating through professional development.
Consumerism in Healthcare
The Australian Constitution provides each citizen with the right to expect justice. In addition, the legal system maintains that all Australian people have the right to challenge individuals, corporation's etc if they believe an injustice has occurred. Traditionally however, health service providers have not been regularly challenged in courts of law (Johnston 1999). However over the past decade there has been increasing awareness nationally and internationally focused on health consumer rights. Mair (2000) notes that health professionals are becoming increasingly concerned about litigation as this awareness increases. In addition, she suggests health care consumers expect positive outcomes from health services. It is also noted from the literature that people are becoming more aware of complementary therapies and are requesting their use (Van der Riet & Mackey 1998).
Inter and intra-professional relationships
Health care professionals practice in environments that require professional interaction between service providers, communities and individual consumers. The interaction, which occurs may be positive and result in health outcomes that contribute to the sustainability of rural communities and/or individuals well-being. However, the literature highlights episodes of negative interaction often referred to horizontal and vertical violence, and inter-professional and/or intra-professional bullying. Vertical and horizontal violence is tolerated to a much higher level in nursing than in other organisations (Stevens, 1998).
Evidence based practice
Ustick (1997) contends that there is a growing body of rural nursing research, and asks the question "...why (is) rural based nursing ... not used as the testing ground for new ideas, new treatments, new research in nursing"? Ustick hypothesises that there is a national way of thinking which links rural living with slow mindedness and outdated practice, and that this cultural more has infiltrated health and education policy. Keyzer (1997) concurs and adds that rural universities have not challenged state and federal governments, or competing metropolitan universities for equitable distribution of research funding. Research which looks at rural nursing practice, attempts to define and refine nursing, measures outcomes and provides direction is necessary and valued research.
In the literature there is growing recognition by nurses, that practice must be based on current knowledge. Handley (1996) found that rural nurses felt they needed developed research skills. While she did not clarify what these research skills were, it seems that accessing information, particularly related to drug therapy and interventions is required by nurses. Brinsmead (1997, p.60) contents that rural nurses "... use all types of information in their practice and are aware, whether instinctively or voluntarily, that this information should be up-to-date in order to provide quality care for clients". The accessing of information for many rural nurses is difficult given the levels of telecommunications available, and reluctance (anecdotal evidence suggests that hospital libraries predominantly subscribe to medical texts and journals over nursing material and the costs of journal subscriptions are inhibitive for many health services) by health services to provide significant resource materials (Hovel, Blue and Kirkbridge 1998). Brinsmead (1997) in her study identified that while nurses are motivated to seek information on specific issues, topics which impact on their practice they do not always know how or want to learn how to access information (Hovel et al 1998).
Educational providers have a responsibility to include research skills in their programs. These research skills should cover many elements including:
- Research methods,
- Evaluation and critique of published research,
- Application and adaptation of research findings to fit rural nursing practice and hence develop relevant nursing practice guidelines, and
- Systematic evaluation of nursing practice using accepted models.
The provision of education, professional development and training
The provision of education is a major challenge that faces rural nurses. There are two aspects to this education - the preparation of beginning rural nurses and their development once in practice. Although there is much literature to suggest the content of pre-service courses there is little that addresses the fundamental nature of pre- service education. For example should there be courses of different duration and content for those who want to practice in rural locations where the literature indicates practitioners must have advanced skills? The literature does clearly state that rural nurses must have advanced skills but at present new recruits are not prepared in any identifiable way for this practice. Although educational programs are available for registered nurses which cover advanced practice skills for those who chose to avail themselves of them e.g. NSW College of Nursing, University of Southern Queensland have post graduate programs in rural nursing practice. The literature clearly indicates that rural nurses have inequitable access to education, training and professional development that is viewed as essential if health service delivery is to be effective. Barriers to the provision of, and utilisation of education and training are discussed at length elsewhere in this review. However, it is an expectation that the delivery of relevant, accessible and practical programs for rural nurses is a challenge for all educational providers.
Occupational Health and Safety
Work place safety is an important issue particularly in light of the fact many rural health professionals practice in isolated areas without support of other staff or security personnel. Adams (2001) comments that a real workplace issue in rural health facilities is the provision of a safe environment. She asserts that staffing numbers are minimal which poses a treat to personal safety of both staff and patients and of equipment. In addition, Adams points out that there is also a risk to maintaining the privacy and confidentiality of patients and staff.
In a study by Drury et al (2001, p.11) examining the experience of rural mental health nurses, participants described feelings of being unsafe in their day to day practice, explaining that "... there is a lack of supported accommodation services in the region coupled with the geographical isolation mean(s) that the nurses (are) putting themselves in danger by going out alone to see clients" and ... that something need(s) to be done to reduce the risk of harm to nurses". Deans (1997) asserts that nurses are often victims of aggressive behaviours displayed by patients, colleagues and others. While Francis et al (2001) claim that the within nursing horizontal violence perpetrated between colleagues is undermining the workplace and impacting on recruitment and retention of nurses.
Support Networks and Organisations
Handley (1996) identified key associations/ organisations which support rural nursing. These include: The Association of Australian Rural Nurses (AARN), Royal College of Nursing, Australia (RCNA), Australian Nursing Federation (ANF, NSW College of Nursing (NSWCN), Nursinginfo, Rural Information Network, Rural Health Training Units, Regional Networks. These organisations have differing mission statements but all provide support for nurses through professional representation, education and training programs, information access and dissemination and employment/er issues.
Remote and metropolitan nurses interests, asserts Hegney (1999) prior to 1991 were represented politically through professional associations (eg. CRANA; RCNA: NSWCN) which legitimated their claims for credibility but may not have served the interests of rural nurses. Rural nursing as a distinct area of practice remained invisible until the formation of the Association for Australian Rural Nurses (AARN) in 1991. AARN provides rural nurses with a political voice, representation on national and state executive committees and is the conduit for needs of 'bush' nurses to be addressed (Hegney, 1999).
Advanced Practice and Skill Mix
Kreger (1991) in her study argued that rural and remote area nurses have demonstrated a willingness to adapt their practice to meet the needs of the communities in which they work. Hegney (1997) believes that rural nurses practice in an advanced role and that this role must be defined and legislation changed to reflect the 'real' practice situation. Walker (1997,p.25) defines advanced practice as "... a level of practice which has developed well beyond entry level practice and exists in both specialist and generalist practice areas". Price (in Walker 1997,p.25) describes a number of attributes of advanced practice nurses which include;
- A commitment to reflective practice and professional development;
- Is caring, objective and empathetic;
- Has a broad social and political awareness; and
- Acts as a positive role model in showing initiative, a responsible attitude and an ability to explore options and who is;
- articulate in regard to role and language;
- focused upon best patient outcomes;
- capable of advocacy and collaboration;
- prepared at masters level of education.
Bradley and McLean (1996 in Drury et al 2001) point out that there is a need by nurses, other health professionals and bureaucrats to recognise rural and remote nursing roles, the role of the nurse practitioner, to acknowledge and accept the nurse practitioner role, prescribing rights, advanced emergency clinical skills and ongoing competency training.
Keyzer (1997) investigated the relationship between the advanced rural nurse and the rural doctor. Keyzer finds that the relationship between the two groups of health care professionals has complex and interrelated roles.
These roles are viewed as being complementary to each other in any healthcare setting, but more so within the context of rural Australia. The current move towards the development of advanced nurse practitioner roles is often clouded by unnecessary medical fears that nurses are attempting to displace doctors.
In contrast, this paper argues that the development of new rural nursing roles identifies rural nursing as a major specialist area within the wider profession of nursing and, at the same time, recognises the reality of practice for many rural nurses. Individual public figures may perceive the solution to the shortage of rural doctors to lie in their replacement with nurses. However Keyzer feels that the nursing profession will resist this approach. The paper concludes that
Nurses are educated and acknowledged to focus their practice on the clients' responses to healthcare problems and not the practice of medicine. The primary role of the nurse is to provide care. The primacy of care should not be set aside by those nurses seeking to develop their practice, not should advanced practice be defined in terms of taking on tasks previously carried out by other healthcare professionals.
Nurses practising in rural environments with limited or no medical support must be prepared to face all challenges as they present. It is clear that many rural nurses are required to have advanced practice skills and some of these nurses will seek credentialling as nurse practitioners. Walker (1997) deems that competency standards are suitable for articulating advanced practice and for providing benchmarks for assessment purposes. However she believes that generic competency standards are not suited and advocates the development of specific competencies for speciality and/or advanced practice.
Rural nursing practice by definition occurs in environments with limited or no collegiate, medical and other support. It may therefore be inferred that nurses who practice in these environments may need advanced practice skills to meet needs as they present. Cramar (2000) points out that it is well documented that nurses in isolated and rural environments perform extended or advanced practice roles. She cautions however, that advanced practice should not be confused with extended practice which she defines as "... as stretching outward to make it go further" (2000,p.29).
Wicks (in Germov, 1996) indicates that the sociological writings about nursing paint a negative picture of medical dominance. She acknowledges there is a difference between the image portrayed of nursing as 'handmaiden' and the real life situation and cites instances in which nurses have not conformed. In rural nursing practice there is ample evidence which is testament to nursing's refusal to accept dominance which has limited the scope of practice to the detriment of health consumers. Indeed Cramar (2000) contends that nurses should be careful not take on "gap filling roles" as there is little evidence to support the success and/or failure of such initiates. Cramar advocates that nurses should advocate on behalf of communities demanding those equitable services. She concludes that many nurses are not prepared to take on advanced practice roles and should not be expected to. Nurses who wish to practice in such roles must be adequately prepared and understand the ramifications for nursing.
Hegney (1997) deduces that medicine is threatened by the emergence of advanced practice nurses who seek independence through legitimisation of the role as Nurse Practitioners. Further, she argues that nurses have not acquiescenced to medicine's continued attempts to maintain control over nursing practice. She sites strategies used by nurses to resist medical dominance which include:
- Resistance through non-compliance to medical orders. That is, rural nurses used tactics to select which aspects of the extended role they would use and when and where they would consult with a medical officer or allied health professional; continuing to work within an extended role despite the legal dilemma; and
- Having local agreements with medical officers to overcome institutional rules and regulations (Hegney 1997,p.20).
In the study by Handley and Blue (1998) they found that 33% of nurses in their study indicated that they performed procedures for which they were not legally qualified. These procedures were categorised and include:
- drug administration;
- suturing;
- intubation or catheterisation;
- cannulation;
- radiotherapy;
- physical assessment and diagnosis;
- defibrillation;
- mental health & counselling;
- midwifery; and administering anaesthetics (Handley & Blue 1998, p.20).
They indicate the most common area of unreported practice was related to drug administration.
Drury et al (2001,p.7) argue "the Council of Remote Area Nurses Australia (CRANA), Alcorn and Hegney (2000) support the role of the rural and remote nurses as nurse practitioners practicing at an advanced level in their report on recruitment of nurses to the bush. The HDWA (2000) has endeavoured to address this through their project on the Remote Area Practitioner. In this report it is suggested, that the training is formalised through the completion of a recognised post graduate diploma accredited by the Nurse's Board and that legislative changes are made to legitimise the advanced practice role performed by some nurses in rural and remote areas. These changes it is argued must include: standard orders for medications, to allow remote area nurses to prescribe and dispense specified medications, following assessment of clients and diagnosis of certain conditions (Drury et al 2001).
In rural environments the composition of the health workforce is determined by the degree of rurality. A number of studies have shown that rural Australia is under served by general practitioners and specialists (Medical Workforce Data Review 1995, NSW Health Department 1995, Overs, M. 1989, Rosenman, S.J., Batman G.J. 1992). In Australian capital cities there are 1043 people per general practitioner and in rural Australia there are between 1400 and 1745 people for every general practitioner (Commonwealth Department of Health and Family Services: 1996). This reduced access to medical practitioners and allied health professionals has led to an increased scope of professional practice for rural nurses than for their metropolitan colleagues. This greater scope of practice is characterised by an increased independence (Anderson & Kimber 1991) and a greater generalisation of skills and a wider clinical experience (Hope: 1993, Sturmey & Edwards 1991).
The NRHA (2001) raise concern that the number of enrolled nurses to registered nurses increases with rurality. They believe that health outcomes maybe compromised as these areas are characterised by limited access to medical and other health professionals. In a survey Huntley (1995) found that rural nurses enjoyed the variety that rural nursing provided. It is well recognised that because there is little access to other health care professions rural nurses need broad scope of knowledge to aid their clinical decision making (Spencer 1998; Kreger 1991; Harris 1992; Buckley & Gray 1993).
The areas that they need good working knowledge of have been identified by Thornton (1988), Kreger (1991) Harris (1992), Buckley and Gray (1993) as knowledge of primary health care, health promotion, child and family health, mental health, aged care, communication and counselling skills, community development, occupational health and safety, acute and chronic medical care, first aid, emergency care and palliative care.
Rural nurses often perform tasks that are performed by medical doctors and allied health professionals in metropolitan areas (Reid: 1994, Thornton: 1992). Bradley and McLean (1999) have described the development of the nurse practitioner role in the form of the nurse led service. They have also identified issues that are impacting on the nurse practitioner role within Australia:
- General medical practitioner resistance to recognition of the nurse practitioner role, especially related to prescribing rights
- Inconsistent general medical practitioner support for the nurse practitioner
- Recruitment issues for attracting health care professionals into the rural and remote sector
- Knowledge deficit within the nursing profession about the scope and practice of rural and remote area nurse
- Education issues and ongoing competency attainment
- Professional isolation
In performing a wide range of roles rural nurses often have to have reduced emphasis on official policy and union rules (Thornton: 1992). This can leave the rural nurse vulnerable from a legal perspective. The National Rural Alliance (1998) proposed the introduction of a nurse partitioner role, which would legalise some of the extended role practices.
Hegney et al (1997) analysed the role and function of rural nurses. They found that the size of the health service (defined by the number of acute beds) influences the activities of rural nurses. They assert that the size of the health service is an outcome of rurality (small population densities, distance from larger health facilities, lack of on-site medical and allied health staff). They also noted that the size of the health service is a factor related to patient acuity and staff skill-mix in small rural hospitals, and therefore the scope of rural nursing practice.
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