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
Mentorship and Preceptorship
Mentorship and preceptorship are seen as important aspects of nursing education. Within an area of practice as complex as rural nursing practice it is thought that mentorship would be particularly valuable. Shaiman and Inhaber (1985) define preceptors, as an experienced nurse who carries out one to one teaching of new employees or nursing students in addition to their regular duties. Alternatively Pierce (1991) describes preceptors as an intense, one on one, reality based clinical rotation for a student nurse whose learning experience are coordinated and supervised by a staff nurse.
There may be a reluctance suggests Hegney et al (1993) for some nurses to act as preceptors due to other commitments and a belief that training of student nurses is not a part of their role. With staff shortages it is thought that this attitude may be becoming more common among rural nurses.
Pre-registration education
All nurses who wish to become licensed practitioners require pre-service education. The preparation of registered nurses pre 1985 was an apprenticeship style training program offered in hospital based Schools of Nursing. However from 1985 Australia embraced the global trend of Baccalaureate preparation for pre-service registered nurses. All Australian single baccalaureate nursing degrees prepare graduate nurses to practice as generalist nurses who are employable in most states in a diverse range of practice settings; acute care, aged care, mental health, community health, correctional services. The Australian Council of Deans (1994 in Duffy et al 1998) believe that since the transfer of nurse education to higher education institutions, undergraduate programs have been inadequately funded. They claim this has occurred because of "... arrangements between the state health and education authorities in determining labour force demands and funding levels. The AARN (2001) identified inadequate financial support for nursing by the Federal and State/Territory Governments as a significant factor impacting on recruitment and retention. Further, they maintain that " there are an inadequate number of nurses being enrolled in degrees to meet workforce needs. This is linked to inadequate consultation between workforce agencies and universities and DETYA with regard to funding" (AARN 2001).
On completion on undergraduate programs graduate nurses, even if educated in rural universities are not returning to the rural sector to work (AARN 2001). The AARN (2001) claim that "... a very small percentage of graduates are going to rural areas. Most good graduate programs are conducted in large metropolitan hospitals and this is where they tend to stay". While Duffy et al 91998) believe inadequate funding has led to many rurally based nursing students having poor clinical experiences which has negatively impacted on recruitment of graduate nurses to rural areas.
Enrolled nursing practice "... has evolved and altered over the years in line with structural changes, differing organisational needs and modifications in health care delivery systems" (Owens & McCarty 1998, p.4). Enrolled nurses complete an educational program provided through the Technical and Further Education (TAFE) system while employed as a student enrolled nurse in a hospital which participates in enrolled nurse education. Like registered rural nurses, enrolled nurses working in rural areas fulfil a diversity of practice roles.
The NRHA (2001) notes that with increasing rurality the proportion of enrolled nurses to registered nurses increases. This suggests that enrolled nurses are more easy to recruit to rural and remote areas than are registered nurses. The question raised, therefore is this trend linked to educational preparation?
Access to education, professional development and training at the post registration or enrolment level is consistently reported as difficult (Hegney 1997; Handley 1996, Kreger 1991, Owens & Macarty1998). For enrolled nurses however, the development of university bachelor of nursing programs for enrolled nurses using distance education, is a beginning attempt to reduce such barriers (Owens & Macarty 1998).
Gibb (2001) while acknowledging the importance of degree registered nursing preparation argues that a transfer of nursing into tertiary education has removed from the nursing workforce a nursing labour force that once trained in small rural communities where local hospitals were major providers of employment. Gibb advocates strategies including a two partnership model which includes local health providers and Technical and Further Education Colleges (TAFE) as well as the universities to overcome demographic and socioeconomic issues which have effected rural employment. Gibb also notes, as does Lawrence (1987) that limited access to education has, and continues to be a major problem in recruiting rural residents for tertiary education. The non-tertiary educational background of parents tends to reproduce career limitations.
Huggonson (2001) suggests that universities need financial assistance to offset the costs of educating Aboriginal nursing students from rural and remote communities. This follows "... recommendation 31 of the report of the inquiry into Indigenous health by the House of Representatives Standing Committee on Family and Community Affairs..." (in Hugggonson 2001, p.2/5). This measure, Huggonson suggest will provide stimulus to disadvantaged rural areas.
In reviews of the literature by Hegney (1996) and Handley (1996 ) there was little literature regarding preparatory training and education for rural nursing. It was noted however that some universities offer rural and remote electives for student nurses. A number of rural Universities and Universities with rural campuses offer pre-registration nursing courses in rural Australia, although a new double-degree 4 year pre-registration course Bachelor of Nursing/Bachelor of Rural Health Practice has developed and will begin in February 2002 . Rural Universities offering undergraduate pre-service nursing programs tend to be situated in regional centres and most are internal on-campus programs. Becoming a nurse in a regional University is expensive. Often regional centres cannot support all nursing students in the centre's University. Nurses have to travel to gain all there clinical costs. This gives them costs that metropolitan nursing students do not have to endure.
Huntley (1995) found that one of the main reasons for nurses choosing rural work was rural background and family relationships. This would seem to indicate that recruitment of rural people into nursing programs is very important.
Post-registration education, professional development
In her review of the literature Handley (1996) identified a number of factors which are barriers or hinder rural nurses from planning and proceeding with further education. These were:
- family commitments (particularly child care and responsibilities in family business)
- distance from educational institutions
- a lack of access to relevant and appropriate courses workload/lack of relieving staff/no study leave
- lack of information about available courses
- lack of funding (both personal and institutional)
- lack of time, both personally and professionally
McManamny: (1996) found that the barriers had been exacerbated by:
- increasing financial restraints in health care agencies
- downsizing of nursing staff
- problem with locum replacement for staff undergoing continuing education
- increasing costs of education programs
- a fragmented approach to the provision of continuing education in rural areas
- an increasing withdrawal of management and employer support for continuing education.
McManamny: (1996) also found that there was a high level of dissatisfaction among Victorian nurses about the apparent lack of support and the level of cooperation from the university sector. This lack of support was seen as the universities not providing courses that meet the needs of the rural hospitals or registered nurses.
Blue (1993) notes that rural nurses are more likely to undertake tertiary postgraduate study if there is:
- a (rural) university campus relatively near
- family support and encouragement
- flexible delivery styles of education
- employer sponsored study
- more information about available programs
- more places made available
- course content relevant to rural needs
- workplace recognition for study and eventual qualification
- options to study over longer periods of time than traditionally allowed
- no compulsory residential module
- scholarship and peer support
A large-scale study of 780 rural nurses was undertaken by Harris (1992) to determine what rural nurses wanted to study. It was found that the top ten priority areas identified were:
- Pharmaceuticals and pharmacology (chosen by 17% of respondents)
- Accident and emergency (chosen by 8% of respondents)
- Diabetes (chosen by 7% of respondents)
- Cardiac care (chosen by 6% of respondents)
- Paediatric care (chosen by 5% of respondents)
- Midwifery (chosen by 4% of respondents)
- Geriatric care (chosen by 3% of respondents)
- Resuscitation (chosen by 3% of respondents)
- Nursing procedures and processes (chosen by 3% of respondents)
- Nutrition and diet management (chosen by 3% of respondents)
In the same study it was found that the top ten skills that rural nurses wanted to develop were:
- Counselling skills (chosen by 19% of respondents)
- Health Education and Promotion (chosen by 15% of respondents)
- Financial management (chosen by 14% of respondents)
- Management/Administration (chosen by 13% of respondents)
- Computer skills/systems (chosen by 8% of respondents)
- Teaching skills (chosen by 7% of respondents)
- Communication skills (chosen by 7% of respondents)
- Human resource skills (chosen by 6% of respondents)
- Time/self management skills (chosen by 5% of respondents)
- Accident and emergency skills (chosen by 5% of respondents)
Another study conducted by Buckley & Gray (1993) in South Australia using a different methodology established rural nurses' perceived needs for future education needs. The top ten responses are shown below with the percentage of respondents who felt that they need each need in their future education:
- Legal aspects of nursing care (chosen by 90% of respondents)
- Teaching skills (chosen by 82.6% of respondents)
- Counselling skills (chosen by 81.1% of respondents)
- Problem solving and decision making (chosen by 79.3% of respondents)
- Bereavement (chosen by 77.3% of respondents)
- Communication skills (chosen by 77% of respondents)
- Physical assessment skills (chosen by 77.2% of respondents)
- Health education skills (chosen by 76.8% of respondents)
- Nursing standards (chosen by 76.5% of respondents)
- Leadership skills (chosen by 76.2% of respondents)
From these studies it is concluded that the following course content be given priority when developing post registration courses for rural nurses:
Clinical
- Pharmaceuticals and pharmacology
- Accident and emergency
- Diabetes
- Cardiac care
- Paediatric care
- Midwifery
- Geriatric care
- Resuscitation
- Nursing procedures and processes
- Nutrition and diet management
- Physical assessment skills
- Nursing standards
Education
- Health Education and Promotion
- Teaching skills
Management
- Financial management
- Management/Administration
- Computer skills/systems
- Human resource skills
- Time/self management skills
- Leadership skills
Generic
- Communication skills
- Legal aspects of nursing care
- Counselling skills
- Problem solving and decision making
From the previous discussion of modes of delivery it is concluded that rural nurses appreciate courses which have face to face content, and have "hands on skill" development. It was also found that rural nurses do not like distance education courses or computer based courses. These facts pose significant challenges for educational providers, as nurses are restricted in their ability to leave the workplace. This may mean that the most appropriate style of course delivery is an "out reach" distance education model where the educator visits the workplace. This is an expensive model to provide and does have resource implications for the employing authority.
Handley (1996) notes there is little recognition of prior learning and limited opportunity for credit transfer when nurses apply to universities for enrolment in courses. Coupled with a lack of employer support, and lack of recognition of postgraduate studies by nursing and employers leads to reduced motivation. There should be more opportunity for credit transfer rather than stand alone courses (Blue 1993, Buckley and Gray 1993, Hegney 1993) which will lead to a more mobile, broadly educated rural nursing workforce (Howe-Adams 1992). It has also been noted from the literature that rural nurses require advanced generalist education. This could best be provided by nurses utilising a range of subjects from different universities using a "pick and mix" model. However, as established the credit transfer mechanisms between universities limits the flexibility of such an approach.
It is argued that rural nursing must be supported by strategies which assist them to access and complete educational programs. This may be achieved through the establishment of Nursing Development Units similar to those in the United Kingdom (Wright 1989). The authors conclude that such a strategy must be separate to other initiatives including the Divisions of General Practice and University Departments of Health which have focussed their activity on medical practice at the expense of nursing and allied health.
Any comments or queries should be sent to: highered@dest.gov.au
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last updated on Tuesday, 04 December 2001
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