Can generalist nurses be specialists? How can a rural secondary nursing service be sustained into the future? Two writers argue the concept of the generalist as specialist must be developed, along with appropriate education.

In the February edition of Kai Tiaki Nursing New Zealand, NZNO professional nursing adviser Susanne Trim reported on the sixth International Council of Nurses' Credentialing Forum in Copenhagen. (1) Among the issues raised was the question: could generalist nurses be considered to be specialists? This question is timely, particularly within the New Zealand rural nursing context and we thank Trim for raising it for discussion.

This article outlines our observations about the nature of health services provided in the rural secondary care setting and the effect traditional education, service structures and increasing subspecialisation is having. We argue that, in order to sustain a rural secondary nursing service into the future, the development of the concept of the generalist, as a specialist, is important.

Around 30 percent of the population in some rural, areas such as Otago/Southland, and 10 percent of the population overall, rely on rural health services. These services are experiencing recruitment and retention challenges that threaten their ability to provide acceptable, accessible care. One of the reasons for this could be the view that a career in rural health is a career backwater.

In urban hospitals, services are commonly provided by specialist staff in dedicated units--paediatrics, emergency, respiratory, gynaecology, orthopaedics to name a few. In contrast, rural, hospital nurses are required to provide a comparable standard of care to a client group that potentially encompasses all these diagnoses with relatively less medical support. Thus rural hospital nurses require wide knowledge, skills and therapeutic interventions to deliver care competently and confidently.

In some larger rural base hospitals, such as Grey Hospital in Greymouth, a solution being posited to address the challenge of providing communities with a range of services is to replicate the model adopted by smaller rural hospitals. This model combines or co-locates specialty services, so clinical staff with the requisite skills are concentrated in one place. Such an arrangement would provide the best use of precious intellectual, technical and fiscal resources. The ideal health professional to work in such an environment would have a welt grounded generalist education and a broad knowledge and skill base.

Suitably equipping the rural secondary care nursing workforce for their future work is a pressing consideration. A well prepared pathway for the specialty of "generalist" requires challenging historical and structural impediments.

Up until 25 years ago, rural, hospital nurses would have sharpened their generalist skills by working with a broad range of diagnostic groups, within a team geared to teaching. However, rural hospitals no longer have training schools attached and those trained in this tradition are part of an aging workforce. The current method of placing student nurses in mainly urban and specialty-based practicums and, after registration, offering education along specialty lines, is a barrier to advancing the legitimate role of the rural secondary care generalist specialist.

Rural immersion programmes

Flinders University in Adelaide, Australia, has an important lesson for rural health services in New Zealand, in its development of a rural immersion programme for medical students. A similar programme is being rolled out at the University of Otago's School of Medicine under the auspices of Pat Farry. Flinders University demonstrated that this approach results in graduates who are more likely to choose a rural career than those students who progress through traditional educational pathways. This process could be similarly applied to nursing and allied health, and a tailored postgraduate educational pathway would complete the career continuum for rural secondary care nurses.

Structurally, the anonymity of the rural nursing workforce in New Zealand is further compounded by the lack of statistical data on this sector. The current Nursing Council methodology of data gathering does not encompass the option of either rural primary or rural, secondary as a choice when nurses identify their area of practice on their annual practising certificate renewal form. While rural nursing data remains submerged in broader nursing categories, the tracking of this workforce remains difficult and makes future planning of workforce capacity and educational requirements haphazard.

In developing a career pathway for the rural generalist specialist in the secondary sector, it is important to have clinical and educational progress clearly delineated. Work is underway to develop such a career pathway. Earlier this year, nurse leaders from Central Otago, Oamaru, Balclutha, Gore, Maniototo, Queenstown and the West Coast formed a group to begin to address this situation. The group's intention is to develop policymaker and employer knowledge around the issues and to build a groundswell of interested health service providers nationally to lobby for an education programme to support the practice development of rural secondary care nurses. Further discussion on this work is planned at the Rural Health Symposium in Christchurch next month.

This is an exciting time for rural nurses. We believe generalists are specialists. The work we are beginning to champion is designed to ensure there is a firm basis for this assertion.

Reference

(1) Trim, S. (2007) Subspecialisation--Is it good for nursing? Koi Tiaki Nursing New Zealand; 13: 1, 23.

Jane O'Malley, RN, PhD, is director of nursing and midwifery at the West Coast District Health Board.

Jan Fearnley, RN, BA (Soc Sci), PG Dip (Hlth Sci), is director of nursing at Central Otago Health Services Ltd.