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
Communication
Leadership
Counselling
Cultural Sensitivity
Legal and Ethical Practice
Assessment Skills
Conclusion
Interpersonal skills
Management
Practice skills
Education
Research
Core skills
Introduction
Practicing in rural environments requires health professionals to be innovative, creative and flexible and be responsive to needs and presenting situations as the socio-cultural, political and economic climates in which practice takes place is largely determined by extraneous factors. The 1995 NSW Statewide Nursing Skills Audit and Needs Analysis contends that the rapid changes in nursing technology and focus require constant updates to identify skill gaps pre and post-registration. This identification needs to be combined with ongoing managerial reform and policy control to accommodate change and delivery for cost effective care. Bushy (2000,p.10) points out that a "... conceptual basis for rural nursing practice is in its infancy but is expanding quickly." She further argues that rural nursing practice is context specific but requires a nursing workforce, which is able to perform in an advanced practice role. Rural nurses "... have total responsibility for all aspects of health care when medical practitioners are not available" (Kreger 1991,p.13). As noted earlier, rural and remote areas have less access to medical practitioners who Humphreys & Rolley (1991) claim have a heavier workload when compared to urban counterparts. Kreger (1991) maintains that this situation has resulted in an expressed need for nurses to back-up medical practice.
Best (200) claims medical practitioners are often deterred from practising in rural communities because of the expectation that they will need to be generalist medical practitioners. Nurses who practice in rural environments are by necessity required to have a broad range of well-developed generalist skills underpinned by a sound knowledge base. It is argued by many, that lack of recognition for the skills required to practice as a rural nurse by employers, the profession, other professions and the community, discourage nurses from seeking employment and staying in rural areas (Hegney et al 1997).
Handley (1996,p.7) maintains that rural and remote nurses may lack advanced practice skills and may not be prepared adequately when first taking positions. She suggests many new rural and remote nurses have:
- Inadequate preparation to perform an extended practice role including performing procedures traditionally considered medical practice;
- Limited skills required to work with different cultural groups; and
- Lack skills to deal with professional isolation.
A study by Sturmey and Edwards (1991 in Handley 1996) found that nurses believe that skills in cultural sensitivity are fundamental to their practice. They further identified that they required well-developed counselling, administration, management, and team leadership skills. Harris (1992 in Handley 1996) asked participants to identify and rank competencies needed by rural nurses. These include;
- Counselling;
- Management and administration;
- Financial management;
- Computers/systems;
- Health education/promotion;
- Law;
- Human resource management/development;
- Pharmaceuticals and pharmacology;
- Accident and emergency;
- Geriatric care;
- Quality assurance;
- Teaching;
- Aboriginal/other cultures or languages;
- Writing and research;
- AIDS/HIV infection; and
- Physical assessment.
Handley (1996) reports other studies indicate that rural nurses need post-registration qualifications in midwifery, community health, child health, mental health, primary health care, critical care, accident and emergency and occupational health and safety. While Cleasby (1997) claims that rural nurses must be able to provide effective mental health nursing interventions and prevention strategies. Cleasby (1997,p.51) concludes that rural communities are being adversely affected by factors including the "... economic down turn, state and federal government policies regarding health services, the peculiarities of living in small communities, and the chronic shortage of health professionals ...". These factors are reported to be contributing to the significantly higher levels of mental illness in rural and Aboriginal communities (Nutbeam, et al 1993). Rural nurses must therefore, have skills which allow them to develop, implement and evaluate health promotion activity designed to raise awareness about mental illness and to act when a crisis presents. A report on the Education, Training & Professional Support for Rural Nurses nationally by Jones and Blue (1998) found that Rural Health Training Units are providing programs for nurses focused on clinical issues including wound care, advanced life support and diabetes management. In addition, these training units provided programs on topics, which include; Cardio-Pulmonary Resuscitation, grief counselling, preceptorship, child and adolescent health, Intravenous therapy, clinical pathways, rural midwifery, appraisal and review performance, leadership, communication, pain management, emergency care, immunisation, research, pharmacology, drug and alcohol, stress, trauma nursing, and advanced clinical skills.
Marginson (1993 in Reid 1994, p.45) argues that there is ongoing debate about employability of graduate nurses. He maintains employers want nurses who are competent and who also possess generic skills that he lists as including;
Communication: listening, understanding, speaking, reading, written communication in its various forms, electronic communication, management of communication systems.
Cognitive attributes: the capacity to identify underlying assumptions, logic, quantitative thinking, orderly thinking, reflective thinking, critical thinking, imagination, creativity, lateral thinking, curiosity.
Knowledge centred attributes: command of/ability to access information, breadth of knowledge, grasp of knowledge systems, capacity to conceive knowledge required, capacity to build on [previous knowledge and experience.
Interpersonal Skills: friendliness and empathy, persuasiveness, team skills, capacity to discuss issues in a group, capacity to respond sensitively to others, capacity to relate with others from different backgrounds and experience, diplomatic skills and tact, capacity to negotiate and achieve results.
Work Context: ability to conceive issues and problems relevant to work requirements, capacity to treat new situations as problematic and 'solve' them, quick and efficient responses, following through a project from design to execution to evaluation and review, entrepreneurial flair, management functions.
Meta-attributes: generalising, synthesising, uniting, independent thinking, capacity for supervised initiative, self-management, intuition, mature judgement, leadership, outcomes focused, confidence, flexibility, adaptability.
Reid (1994) identified core skills expected of all graduate registered nurses when applying for positions. These attributes are common expectations reported in the literature of all nurses and include;
- Effective interpersonal skills
- Verbal and written communication skills
- Analytical skills
- Leadership and management qualities
- Teamwork
- Problem identification and solving
- Creative
- Lateral thinking
Health consumers indicate that they want nurses who have the following characteristics:
- Are responsive to their needs,
- Are congenial in their interactions,
- Are competent, and
- Provide education ( Webb 1995).
Rural nurses are often in positions where they are known to their communities. For many nurses this is a benefit in terms of understanding the environmental, socio-political and economic issues, which may underlay client presentation for health services (Hegney et al 1997). Hegney et al (1997,p. 247) maintain that rural nursing practice is different and that the following attributes characterise rural nursing practice:
- Knowing the community,
- Caring for relatives and friends,
- Lack of anonymity,
- Isolation from support services, and
- A broad range of skills and knowledge.
Offredy (2000) examined advanced nursing practice as it relates to rural and remote areas and found that competencies, accountability, diagnostic imaging, diagnostic pathology, prescribing of medications, and referral procedures were routinely part of advanced nursing practice. Hegney (2000) claims that rural nursing practice has remained invisible as nursing education has traditionally been based on a medical model. She asserts that as advanced nursing practice in rural areas expands, recognition of the rural nurses' role will increase and the advantages of educating nurses for rural practice using a new framework will ensure that rural nursing meets community needs.
Therefore the literature begs the question how should nurses be prepared for rural nursing practice? Should nurses be prepared for rural practice during their undergraduate study or should this be left to post graduate studies? If the skills and knowledge are to be included in undergraduate courses these will have to be lengthened to include extra topics as identified in the literature. There may be grave problems associated with leaving this education to a post graduate level however. It will be argued later in this review that rural nurses have limited access to post graduate education, training and professional development due to a number of factors. If acquisition of these important skills and knowledge is left to post registration it may be problematic. The issue of core skills is re-visited and elaborated on, both in the section of this review that covers education and in the section on practice challenges. The following are some of the identified core skills rural nurses indicate are required for practice. Much of the literature indicates that rural nurses have these skills but are concerned their level of skill is not as well developed, as they would like.
Any comments or queries should be sent to: highered@dest.gov.au
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