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
Communication
Effective communication skills are an essential attribute of the nurse (Reid 1994; Lubbers & Roy 1990). Nursing asserts Stein-Parbury (2000,p.3) is a social activity which involves "... knowing, doing and being". She argues that nurses must be effective interpersonal communicators which is defined as "... interactions with patients which are helpful to the patients" Stein-Parbury (2000,p.3). Lubbers & Roy (1990) proffers good communication skills are an essential element in nursing practice and warns, poor communication can lead to litigation and or result in harm to patients. The six, most important communication skills identified by the Lubbers and Roy (1990) study include:
- Listening
- Relationship building
- Instructing
- Motivating
- Exchanging routine information
- Giving Feedback (1990, p.112).
In addition, Lubbers & Roy suggest that communication skills do not feature in staff development programs. However many studies provide examples of the importance of communication as a diagnostic and therapeutic tool used by nurses. Hall (1997,p.83) describes the nursing practice of district nurses in a rural area as involving a
... complexity of physical tasks, technical procedures, assessment based on knowledge and additionally social acceptance and understanding need within a given context. Complexity reflected the tasks performed , 'degree of difficulty', and viewing the patient as a person. This implies being aware of each patient's life within the context of their daily reality. Lifestyle, needs and values are heard as the patient is showered; still talking, assessing and following lives concurrently. Constant maintenance, constant assessment, and constant prevention or intervention; embedded in a knowledge base, deep and complex; supported with interpersonal sensitivity and acceptance.
Leadership
Working intimately with patients, the community and other health professionals require leadership skills. Leadership is providing resources and information to support decisions ( Sullivan, 1999). Sullivan (1999) suggests that the information used in leadership drives the health care system by "... producing integrated clinical and financial outcomes". While Sullivan & Decker (1988 in Siegloff 1998,p.213) claim a leader "... uses skills to influence others to perform to the best of their ability". Leadership involves a synthesis of interpersonal skills and as Blanchard (1995 in Sullivan 1995) states, effective leaders have strong convictions, are consistent, helpful, knowledgeable and honest. Siegloff (1998) argues, rural nurses are willing to take on leadership roles to improve health outcomes but often feel unprepared educationally for these roles. Aspects of this core skill are seen to be based in the hidden curriculum of nursing. However, it is believed that leadership should be visible in pre and post-registration programs.
Teamwork
The health literature abounds with descriptions of the health team, inter-professional and intra-professional teamwork. However, there is a growing evidence which argues that working in a mutlidisciplinary team which shares responsibilities and is respectful of each members contribution is mythical (NSW Nurses Registration Board 1997; AIHW 1996). In addition, the nursing literature is scathing of the level of horizontal violence displayed intra-professionally among nurses (Spring & Stem 2000; Short et al 1993; Francis et al 2001). Hemingway & Smith (1999) argue that the flow on effect of such behaviours is manifested in high levels of absenteeism, high rates of staff turnover and may result in people leaving the health professions permanently. Francis et al (2001) suggest that intra-professional and inter-professional violence may be responsible for nurses choosing not to work in rural areas. They argue that in rural areas the numbers of staff are small and there is limited ability for individuals to remove themselves from threatening or abusive situations. This is supported by Hegney (19970 who concludes many rural nursing students who have had negative clinical experiences seek employment in metropolitan areas where the numbers of staff are higher, and therefore the risk of being abused is diluted. Chun-Heung & French (1997) deduce that if student nurses have positive clinical experiences they are more likely to seek employment in these places, and conversely a negative experience deters them from seeking employment in these places.
It is recognised however, that most nursing occurs in situations involving other nurses and/or health care staff. Working in teams is a skill that all nurses must acquire if they are to be effective.
Management
Nurses practising in rural environments may work with other nurses and/or other staff. Inevitably all nurses are required to take on a management role in day to day practice. The reviewed literature suggest that management is the skill of accommodating change and sets the practice tone. It is seen as an essential skill, however, management is also seen as detracting from daily practice. Nurses see management as increasing their role in policy development, while removing them from the hands on approach of nursing (Marles 1988; Ollfredy 1997; Geissinger & Lloyd 2000; Swansburg, 1999). Rural nurses increasingly see the acquisition of necessary management skills as being integral to their role/s. They believe that these skills can only be acquired by undertaking post-graduate qualifications (McCoppin & Gardner 1994).
Counselling
The literature clearly indicates that rural nurses must have counselling skills. Dietsch (1998) claims that counselling is an integral part of general and sexual health nursing practice. This is supported by Cleasby (1997) who acknowledges that rural nurses must be equipped with skills which allow them to meet the mental health needs of rural communities. Handley & Blue (1998) point out that rural nurses surveyed believe that counselling skills are required in rural nurse's daily practice.
Cultural Sensitivity
Australia is a multicultural society and requires health professionals to have a well developed understanding of cultural groups to inform practice (Cameron-Traub in Omeri 1996). Bushy (200) believes that rural nurses globally must be prepared to work with cultural minorities. She indicates that the process of being an effective nurse begins with "... self-other awareness and evolves to implementing nursing interventions that mesh with rural client's health beliefs and expectations, even when these are different from those of the nurse" (Bushy 2000, p.103). For Australian rural nurses, understanding cultural differences between Aboriginal and Torres Strait Islander peoples and others, is fundamental to practice claims Goold (1998). Goold (1998, p.123) quoting Socrates states " ... awareness of one's ignorance is the foundation of knowledge". She further argues all pre-registration nursing programs must include studies designed to familiarise nurses with cultural issues if cultural sensitivity is to become a corner stone of nursing practice.
Legal and Ethical Practice
Issues impacting on professional nursing practice in a rural context will be discussed under the section "Practice Challenges", however it is recognised that a core skill underpinning all nursing practice is the recognition and understanding of legal and ethical issues in every day practice. . Bushy (2000) claims that all nurses must be aware of the legal requirements of practice and understand the principles governing bioethics. Education programs she claims must equip nurses with knowledge about legal and ethical principles and provide them with the skills to justify practice.
Assessment Skills
Nursing work requires nurses to be effective in monitoring health of individuals, groups and communities (Bushy 2000; Sutton & Smith 1995; Ollfredy, 2000). Assessment requires the collection of base-line data that informs the decisions made by nurses regarding intervention planning, service delivery and health promotion and education activity.
Sutton & Smith (1995) assert that rural nurses think, see and experience their practice differently to other nurses. They content, as does Bushy (2000) that rural nurse's style of practice requires an intimate knowledge of the community and of individuals within the community. Sutton & Smith (1995) further state, that the rural nursing practice concentrates on the interpersonal rather than technological aspects of care.
Consistently the literature discusses the need for rural nurses to be familiar with concepts of primary health care and community development. Dunkin (in Bushy 2000,p.63) provides a useful framework which illustrates the factors impacting on health care behaviours of rural people. This framework is useful for rural nurses in planning their practice.
The NSW Registration Board (1997) maintains that beginning registered nurses are often seen by experienced registered nurses as being less confident and competent in their basic assessment skills of individuals and communities. This document also notes that new graduates often over estimate their own competency in assessment skills, especially in rural areas. The challenge for rural nursing therefore, is to provide nurses with opportunity to develop and enhance assessment skills which are considered core skills for practice.
Conclusion
In this section core skills for rural nurses have been described. The list of core skills is not exhaustive and requires ongoing reassessment to identify emergent skills as rural nursing practice becomes visible.
A number of sources have been identified that suggest content for courses which aim to prepare nurses for rural practice. From these sources the following list has been devised. Rather than being a comprehensive curriculum this list should be seen as a set of elements that should be emphasised in programs which are designed to prepare nurses for rural practice.
Interpersonal skills
- Counselling;
- Cultural sensitivity;
- Verbal and written communication skills;
- Effective interpersonal skills;
- Caring for relatives and friends.
Management
- Management and administration;
- Financial management;
- Computers/systems;
- Human resource management/development;
- Quality assurance;
- Leadership and management qualities;
- Teamwork;
- Problem identification and solving;
- Creative and Lateral thinking.
Legal and ethics
- Law;
- Ethics.
Practice skills
- Pharmaceuticals and pharmacology;
- Advanced life support;
- Life span care;
- Analytical skills;
- AIDS/HIV infection; and
- Physical assessment;
- Knowing the community.
Education
- Health education/promotion;
- Teaching.
Research
- Writing and research;
- 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.
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