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
Legal and Ethical Aspects of Practice
Changing technology
Health funding
Consumerism in Healthcare
Inter and intra-professional relationships
Evidence based practice
The provision of education, professional development and training
Occupational Health and Safety
Support Networks and Organisations
Advanced Practice and Skill Mix
Practice Challenges
Introduction
Nursing in rural environments in the 21st century will pose many challenges. From the literature major issues facing rural nursing have been identified. These include recruitment and retention of rural nurses, practice issues such as legal issues, changing technology, and the work environment. It is recognised that the rural environment is responsive to extraneous factors such as national and international economies, political ideology, and climatic conditions. This section of the review will discuss these issues with reference to how they impact on nursing practice in rural areas. One way in which rural nursing practice has responded to these factors is the development of the philosophy of advanced practice and an investigation of skill mix issues. These aspects of rural nursing will also be examined in this section.
Educational providers, policy makers, the health service authorities and professional bodies must address the issues that are identified in this section.
Recruitment and Retention of Staff
Recruitment and retention issues and rural nurse shortages have been discussed previously in this review. It is noted that these issues will become most problematic in 2010 as the current rural workforce retires (Hamilton 2000). It is proffered that employers, education providers and rural communities must focus their efforts on addressing the challenge of the recruitment and retention of nurses (Simpson 2000).
As discussed in the literature nurses who choose to practice, and who remain in rural areas are committed to the community through families and partners (Hegney 1997). Attracting nurses to rural communities who do not have these ties may require the development and implementation of collaborative strategies between employers, local councils, government and others to develop incentive programs which support nurses and their families in relocating and remaining in rural communities. Furthermore, the review has identified workplace issues, which are perceived by nurses as deterrents to practicing in rural environments. These issues are discussed more fully in this section and include safety, intra- and inter-professional relationships, maintaining currency and specialist skills, and access to education etc.
It is suggested that rural nursing practice is advanced nursing practice (Hegney 1997; Hegney et al 1997; Bushy 2000). If this is accepted then education providers must develop and/or modify programs at the pre and post-registration level to prepare and support nurses practicing in rural Australia. In addition, education providers must look to the availability, access, and status of their courses if they are to contribute to addressing the issues raised by a chronic shortage of nurses. The status and profile of generalist nursing practice both within the nursing profession and outside must be elevated and valued by nursing, other health professionals and the community if nurses are to be attracted to this area of practice (Hegney 1997).
Legal and Ethical Aspects of Practice
Australia in the 21st Century will leave a legacy as an era of litigation. All health professionals practice within an environment in which autonomy of practice is demanded by practitioners, and responsibility and accountability for practice and improved health outcomes for actions implemented are expected by professional bodies, and the community (Mair 2000).
Nursing practice in Australia is governed by the ANCI competencies, which were developed to provide standards to regulate nursing practice. The ANCI competencies communicate to consumers the competency standards that they can expect of nurses (Australian Nursing Council Inc., 2002). All registered and enrolled nurses are licensed to practice by nursing registration authorities in each State and Territory in Australia (Reid 1994; Mair 2000). Each State/Territory Nurses Registration Acts regulate and control the profession and provide for penalties for breeches of the Act. While there is similarity regarding licensing expectations across Australia there are also differences between states and territories.
Hegney et al (1997) point out nurses are concerned about negligence and breeching specific legislation in carrying out their duty of care. They assert that nurses should have a sound understanding of the law particularly common law and parliamentary or statute law and provide an overview of the legal requirements attached to the ordering and dispensing of Schedule 4 and 8 drugs. Miar (2000) argues that the very nature of nursing practice requires nurses to be vigilant about understanding the law. She cautions that nurses must recognise that if they claim to possess special skills they are required to exhibit higher standards of care and must be able to prove in court that care provided was to a standard expected if a case of negligence is bought against them. Hegney & Hobbs (1998) states nurses are concerned that they have become deskilled with the downgrading of health services in rural areas because they are unable to practice specialist skills routinely, eg midwifery. Conversely, the same situation has allowed some nurses to develop new skills and enhance their scope of practice (Mahnken et al 1997 in Hegney & Hobbs 1998). Plainly, the message that nurses must hear and respond to, is that they must feel competent and have a knowledge base, which supports their practice. Many speciality organisations, mindful of the legal ramifications, are developing credentialling criteria as a benchmark for practice. For rural nurses this process is more difficult, given the multiplicity of roles expected in a multi-skilled nursing practitioner.
Several studies indicate that many rural nurses practice outside the legal parameters governing nursing practice (Kreger 1991; Hegney et al 1997; Handley & Blue 1998; Spencer in Siegloff 1998). In a study by Cramar (2000) which investigated rural/remote nurses' practice she notes many of the nurses took on medical roles in the absence of medical practitioners, and practised in a manner which she deems did not meet the standards expected of either nursing or medicine. Hegney (1998) argues that many rural nurses are forced to practice outside the legal parameters governing nursing practice. Keyser (1997,p.3) notes that "... rural nurses are often working well outside the legal parameters of nursing and providing services normally undertaken by a variety of healthcare workers". Reasons nurses provided in Kreger's (1991, p.22) study for undertaking practices which were outside legislation and standards of practice include:
- it is not realistically possible to cover all contingencies that arise in rural and remote health services with the human and material resources at present available;
- a medical practitioner is not always available on-site, or by telephone or radio, on all occasions advice or personal intervention is required for emergency or basic health care in rural and remote areas;
- pharmacists, radiographers and other allied health and welfare professionals are not available on-site on all occasions required for basic care;
- many rural medical practitioners, overtly and covertly, expect nurses to exercise their own discretion about the need for medical intervention or advice. The nurse is expected to determine whether he or she is competent to manage the presentation independently irrespective of the need for medical interventions. This perceived expectation can arise from open discussions between medical and nursing practitioners who trust each other, or as a result of nurses receiving professionally irresponsible responses when they do attempt to consult their distant medical colleagues on occasions legally requiring them to do so;
- the time involved in obtaining a medical practitioner's authorisation on every occasion it is legally required would render the remote are a health service, in particular, dysfunctional in relation to the existing primary health care demands on the nurses;
- some distant medical practitioners order nurses to undertake medical procedures and levels of care not appropriately preformed at a remote location, or by a nurse. Cost factors associated with aerial evacuation are perceived by nurses to influence such expectations excessively, however reports on these matters are not confined to locations dependant on aerial evacuation of patients. The consumer's right to safe and appropriate health care, and the nurse's competence and capacity to fulfil extraordinary expectations within a remote community are often ill-considered;
- consumers exert pressure on nurses to adhere to a standard of service based on previous fulfilment of medical, pharmaceutical and radiographic functions. Pressure occurs, particularly, when the alternative for the consumer involves returning for an investigation or therapeutic intervention at a later time or date, a significantly increased waiting time, time consuming travel to another centre or an additional financial outlay;
- nurses attempt to ensure ease of access to health services, and cooperation with consumer and colleague demands, needs and expectations. Nurses' moral and professional obligation to ease or prevent suffering is not related to the presence or absence of a medical practitioner, and frequently overrides the possibility of litigation;
- nurses perceive tacit approval of their expanded practice. This is based on conclusions drawn from the inaction of others with responsibility in these matters. For example, the store or regional pharmacy continues to provide medical supplies and medications in the absence of prescriptions, licences to supply and accreditation certificates. The employer and medical, nursing and pharmaceutical responsibilities in the absence of written or verbal authorisation. The health service administration or regulatory authorities provide no practical alternatives or guidelines that are workable within the existing conditions.
Issues including the principles of ethics, professional responsibility and patient rights have become the focus of all health professionals' practice. Mair (2000,p.124) warns that nursing practice involves touching health care consumers and in "... accordance with common law, all people have the right to determine what treatments or diagnostic tests they will be subjected to, unless there is some overriding law that allows treatment without consent." Consent she claims must be informed consent, which involves the health care consumers understanding of what is to be done and the risks involved.
The law as it relates to ethics associated with research is perhaps not as clear as it needs to be. Chester (2000) indicates research may be conducted and unwittingly or wittingly be in breech of human rights and the law. Nurses like all health professionals are expected to add to nursing's knowledge base through research, and to use research to inform practice. An understanding of the ethical implications of doing research, which maybe applied within the workplace ie patient records, health knowledge assessments etc is fundamental knowledge and will increasingly be part of all nursing roles.
Rural nursing practice presents the nurse with many ethical and legal issues. Surveys have shown that rural nurses are concerned about these aspects of practice. It is clear that some rural nurses work outside statute law in an attempt to provide a quality service (Hegney et al 1997). This leaves rural nurses very exposed to legal action. Anderson (1990 in Johnson 1999) states that because morality is constantly changing people need to be constantly reviewing their own ethical practice.
The literature clearly indicates that nurses practicing in rural areas are often required to practice outside legal parameters. What is also emerging from the literature is a growing concern by nurses about this practice. The authors conclude that if the boundaries of practice are not expanded and legalised then recruitment of nurses to rural and by inference to remote area practice, will continue to decline. In addition, it is asserted that educationalists and employers must provide opportunity for nurses to investigate, discuss and contribute to debate regarding legal and ethical practice. There must be opportunity for rural nurses to raise issues about practice within the community, the profession and at legislative level. Contribution to the discourse will increase nurses awareness of their obligations and understandings of legal issues and will assist rural nurses endeavours to advance practice which is consistent with the philosophy underpinning nursing.
Changing technology
There have been significant advances in technology in nursing practice in the past ten years (Hegney & Hobbs 1998). These advances can be broadly divided into two categories direct medical treatment technology such as patient monitoring, ventilation technology etc and communication technology such as the Internet. The advances in these categories of technology have advantaged some rural communities and disadvantaged others (Humphreys & Rolley 1993). Access to services which are available in major rural centres results in people from smaller communities incurring additional costs associated with travel to access these services. Conversely, for rural centres where these technologies are located the boost to the local economy is substantial and the health services provided more comprehensive (Hegney & Hobbs 1998). Some rural nurses feel that they lag behind their metropolitan colleagues in terms of advances in technology (Handley 1996). They equate rural practice with low technology and inferior practice.
However, it is recognised that increasingly health services are reliant on communication technology. This is evidenced by the common usage of database patient information systems, computerised medical records, and telecommunication systems. Studies have been undertaken to identify nurses' perceptions of technology in the workplace. Hovel et al (1998) found that rural nurses agree that treatment communication technology is used in everyday practice. They also identified barriers to the use of technology which include:
- physical and infrastructure
- personal and professional
- cost constraints
The role of government in providing equitable communication services in rural Australia is a political platform enjoying considerable attention. Key telecommunication giants including Telstra, Vodaphone and Optus are lobbying for financial support from government to provide rural and remote Australia with effective telecommunication systems. These initiatives will increase rural health facilities ability to support information systems etc in the workplace and may reduce professional isolation which has been identified in the literature as a problem for all health professionals (PRHCIT Report 1996 in Hovel et al 1998). If health services provide access to staff to telecommunication services including the Internet access to information to assist in practice will be improved.
Technology has been used to alleviate the isolation experienced by some rural nurses. Technology, which can be used in this endeavour, includes:
- Teleconferences
- Video conferences
- E mail
- List servers
If these utilities are to be used effectively, education providers must include these elements in their courses. There is evidence that Universities are using these technologies to deliver their courses and hence introducing their students to the technology.
Sinclair & Gardner (1997) studied the perception of nurse educators to information technology. The results indicate,
that although there remain tutors who have not received any formal training in computer use, the majority want to use computers and recognize their need for competence. While training would appear to have a positive effect on their perceived level of competence and computer knowledge, the study identifies factors which contribute to the restricted use of computer assisted learning (CAL). Student assessment varies across the province and findings of the study indicate that although many changes have taken place, staff expect more in the future. They identify a need for policies that include training programmes, competence assessment, appropriate technology, and networking.
McKenna & Ribbons (1997) investigated the educational applications of the Internet and World Wide Web. They identified that the role played by the Internet and more specifically, the World Wide Web (WWW or web), will become increasingly important to health care providers. They described how
nurse academics within the School of Nursing, Monash University, have adopted an innovative and integrated approach to Internet technologies as part of information processing and inquiry in nursing. This approach is aimed at enhancing the teaching/learning process by lending additional richness to the learning environment.. Initial feedback from this project supports the assumption that information technology has an important, and increasingly prominent, role to play within nursing education and clinical practice.
Bradley and McLean (1999 in NRHA 2001, p.3) state
the development of health care in rural and remote Australia has, however, heavily relied on the work of nurses. For many years, nurses have provided extensive health services without any readily available access to medical or allied personnel other than via telecommunication.
It is becoming increasingly popular for education providers to offer education using web based learning material. While the arguments for the uses of this technology are sound (Gray 1994), they are problematic for some rural nurses. Many rural communities' lack the efficient tele-communication facilities found in urban and provincial areas, and the associated costs for students to purchase hard and software combined with inadequate access to local computer support, means that this mode of delivery is often ineffective.
Chapter Practice Challenges continues
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