Exploring the complex nature of rural nursing: rural nurse specialists' role is a complex and challenging one, performed, as it is, within the communities in which nurses live.[ILLUSTRATION OMITTED]
Nursing in rural New Zealand New Zealand (zē`lənd), island country (2005 est. pop. 4,035,000), 104,454 sq mi (270,534 sq km), in the S Pacific Ocean, over 1,000 mi (1,600 km) SE of Australia. The capital is Wellington; the largest city and leading port is Auckland. offers unique challenges. One of these is how nurses manage their professional and personal selves while tiring in small rural communities. (1,2,3,4) I undertook a research study last year to gain an understanding of what this means for a small group of rural nurses on the West Coast. My concern about the long-term sustainability and viability of this service was the key rationale for undertaking the study.
Heavy rain and snow and strong winds can isolate the West Coast from larger towns and cities by road. The Southern Alps Southern Alps, mountain range, on South Island, New Zealand, paralleling the west coast. It rises to 12,349 ft (3,764 m) at Mt. Aorangi (Mt. Cook), New Zealand's highest peak. not only isolate the West Coast, they cut it off from the rest of the South Island. Within this context, rural nurse specialists (RNS RNS Regulatory News Service (UK stock market)
RnS Rinnovamento Nello Spirito (Italian: Renewal in the Spirit)
RNS Ribonukleinsäure (German: RNA)
RNS Residue Number System ) provide a comprehensive, nurse-led service to a geographically-defined population, while living in their communities. The RNS works both autonomously and collaboratively to assess, diagnose and treat personal health problems. This includes administering treatments and medications, in collaboration with medical practitioners or under the guidance of approved standing orders. The RNS also provides the prime response in a medical emergency (PRIME) emergency service.
The network of RNS on the West Coast is unique in New Zealand because we have the highest number of RNS working across the largest area. For many years, nurses have provided community, primary health and acute care services to communities, often with limited access to immediate medical assistance.
The RNS have high workloads and tong tong 1
tr.v. tonged, tong·ing, tongs
To seize, hold, or manipulate with tongs.
[Back-formation from tongs. hours, including being on-call for every rostered day they work. Nurses have told me about being unable to relax and enjoy a simple meat at home for fear of being interrupted by the pager. Nurses struggle to maintain a personal life, because high visibility in their communities means that even on their days off some community members expect nursing assistance and knock on Noun 1. knock on - (rugby) knocking the ball forward while trying to catch it (a foul)
rugby, rugby football, rugger - a form of football played with an oval ball
rugby, rugby football, rugger - a form of football played with an oval ball their door at home. A local RNS who resigned cited exhaustion as the reason for leaving, secondary to the long on-call hours. (5)
Four key constructs around the management of the personal and professional serf serf, under feudalism, peasant laborer who can be generally characterized as hereditarily attached to the manor in a state of semibondage, performing the servile duties of the lord (see also manorial system). emerged in the rural nursing literature.
1) Lack of anonymity: This means "taking care of clients who are known through associations other than the nurse/client relationship" (6) and is characterised by visible, identifiable and diminished personal/professional boundaries.
2) The nurse as insider/outsider in a community: An insider is a person who has an understanding of the social context of the community, but is also a life-time member of it (7), eg a person whose family have Lived in a community for several generations. Because of their standing in the community, the insider has access to personal information about other community members. The insider also understands the social norms and values of the community and his/her behaviour reflects these.
The concept of the outsider is very relevant for RNS, as most are recruited beyond the West Coast. The outsider is unfamiliar with the community and is not connected to the group by virtue of family or personal ties. (8) As a consequence, the outsider is not recognised or accepted as a member of the community.
3) Professional and personal isolation: Professional isolation occurs when there is a physical distance from peers, education providers and nursing organisations. Professional isolation has been identified as a key factor impacting on a health professional's decision to work, or remain working in rural practice. (9,10) There are similarities between professional and personal isolation. Personal isolation is a feeling of being alone and disconnected from family and friends. (11) Again, distance is usually a significant factor.
4) Fluid role: This acknowledges the adaptability and generalist gen·er·al·ist
A physician whose practice is not oriented in a specific medical specialty but instead covers a variety of medical problems.
generalist nature of rural nursing. (12) This has been described as nurses working in an extended or expanded role. (13) One researcher suggested that nurses function in multiple and expanded roles that may overlap with those of other health professionals. (2) The need to deal with anything and everything is a key feature of fluid role.
Interpretive in·ter·pre·tive also in·ter·pre·ta·tive
Relating to or marked by interpretation; explanatory.
in·terpre·tive·ly adv. description was a useful method for this small scale qualitative research Qualitative research
Traditional analysis of firm-specific prospects for future earnings. It may be based on data collected by the analysts, there is no formal quantitative framework used to generate projections. , because it sought to obtain personal descriptions from individual nurses and then interpreted those experiences. Four RNS who had tired and nursed in the same rural community for a minimum of 12 months were recruited as participants. They were interviewed face-to-face in a semi-structured interview A semi-structured interview is a method of research used in the social sciences. While a structured interview has a formalized, limited set questions, a semi-structured interview is flexible, allowing new questions to be brought up during the interview as a result of what the that focused on demographics The attributes of people in a particular geographic area. Used for marketing purposes, population, ethnic origins, religion, spoken language, income and age range are examples of demographic data. , the RNS role and ranking the key constructs discussed above. The transcribed interviews underwent thematic analysis. While the interview identified key issues for participants, a follow-up email dialogue verified themes from the initial data analysis.
This research posed significant ethical issues because I was known to all potential participants. To avoid potential coercion and bias in terms of selection, and to ensure participants would not be unduly advantaged or disadvantaged through participation or non-participation in this study, the West Coast District Health Board's (DHB DHB District Health Board (New Zealand)
DHB Deutscher Handball Bund (German)
DHB Deutschen Hausfrauen-Bundes (Darmstadt)
DHB DHB Capital Group, Inc. ) workforce development coordinator for mental health, agreed to be the first contact person. Information about the study was sent to all nurses who met the inclusion criteria
Inclusion criteria are a set of conditions that must be met in order to participate in a clinical trial. . Signed consent forms were returned to the first contact person, who then forwarded the names of the first four respondents to me. The value of confidentiality was paramount. This meant participants' privacy was to be respected at all times. Location and other identifying features were removed from the transcripts. Participants were regarded simply as participants and not given pseudonyms This article gives a list of pseudonyms, in various categories. Pseudonyms are similar to, but distinct from, secret identities. Artists, sculptors, architects
Rural nursing is distinctive. It is different from working in any other nursing context and this finding is consistent with other authors. (1,4) Central to this is the concept that nurses' professional and personal roles are interwoven in·ter·weave
v. in·ter·wove , in·ter·wo·ven , inter·weav·ing, inter·weaves
1. To weave together.
2. To blend together; intermix.
v.intr. . This means the private lives of nurses are inextricably in·ex·tri·ca·ble
a. So intricate or entangled as to make escape impossible: an inextricable maze; an inextricable web of deceit.
b. linked with their professional lives, because nurses deal with community members in a range of settings, on a daily basis. This has also been described in a study of nursing practice in rural and remote Canada. (14)
Although the experience of living/working rurally was generally regarded as positive, participants had less than positive accounts of how on-cart and isolation affected their personal life, creating an imbalance between work and the experiences. "We are on-call 24 hours a day ... nurses have stepped up to the mark and do a lot of on-call, but at a cost--an awful lot is expected from them both by some rural communities and by management. There is only so long a nurse can keep up with the demands of on-call, before looking at other work, elsewhere."
Another negative aspect was colleagues being unwilling or unable to share their knowledge with the team. "I think your professional isolation ... can ... also be affected by people in your closest team. It depends on their ability to share their knowledge ... if ... they have knowledge to share, because some of them don't. And they might have it and they don't share it with you." Another key aspect of isolation was the risk of co-dependency, illustrated in the following words, again raising the issue of professional and personal boundaries. "There's another real risk I think with professional isolation ... you can easily become co-dependent on your community. In other words Adv. 1. in other words - otherwise stated; "in other words, we are broke"
put differently , you need them to need you to feel good. And that's very easy--especially for nurses--because we have this service and giving way of working.
The complexity of rural nursing
Part of the complexity of rural nursing is its generalist nature. It is regarded as generalist because many of the roles traditionally undertaken by other members of the health care team in urban settings, are undertaken by rural nurses in rural settings, eg postnatal postnatal /post·na·tal/ (-na´t'l) occurring after birth, with reference to the newborn.
Of or occurring after birth, especially in the period immediately after birth. care. Nursing practice is also viewed as specialist in nature because the rural nurses have a level of knowledge and skiff in a particular aspect of nursing, ie primary health care--rural. One participant described it thus: "The Jack of all trades--the enormously broad scope of the practice ... I find, for me, that's the most difficult thing I find ... knowing enough--you know a little bit about everything and not a lot about anything. And it's very easy to miss something or forget something or not be quite as ... aware of something.... because you're seeing such a variety of things." Rural nursing takes place in communities. The community places certain expectations on the nurse and these expectations formed the un written rules the nurse was obliged o·blige
v. o·bliged, o·blig·ing, o·blig·es
1. To constrain by physical, legal, social, or moral means.
2. to work within, if they were to succeed in their RNS role. The nurse's role in the community was one of negotiation. Nurses clearly identified themselves as insiders or outsiders in their own or neighbouring communities. However, nurses used insider knowledge to understand the workings of their own communities. (15) The relationship between the nurse and the community could be of mutual benefit to both parties, but certainty worked towards meeting the needs of the community. The nurse was often viewed by the community as the first contact person in the event of an emergency and was considered as a valuable contributor during times of crisis.
Nurses genuinely wanted to provide their community with nursing care of the highest quality but working rurally posed challenges, including access to professional information. The RNS role offered many opportunities to advance their practice and postgraduate education
Postgraduate education (often known in North America as graduate education, and sometimes described as quaternary education was considered an essential part of that preparation. Interwoven professional and personal roles, the complex nature of rural nursing and relationships with the community comprise the distinctive nature of rural nursing. Rural nursing is a distinctive way of nursing--rural nurses are specialist-generalists who use insider knowledge of the communities they live/work/study in, combined with advanced clinical skills to provide a nurse-led service, particular to the unique health needs of their community. Managing professional/personal boundary issues is critical to achieving success in the role.
In collaboration with RNS and NZNO NZNO New Zealand Nurses Organisation , the West Coast DHB is challenged to review RNS' conditions of employment conditions of employment
that part of an employment that sets out the duties, responsibilities, hours of work, salary, leave and other privileges to be enjoyed by persons employed, for example a veterinary nurse, in private practice. and to implement sustainable, local initiatives that address issues around on-call and isolation. Working towards a minimum of two RNS in each location is recommended. Beller use of existing resources could improve supports for newcomers/outsiders. Nurses can Look at more creative ways of supporting each other, eg through group supervision. The role of the multidisciplinary team is important, especially the professional relationship with medical staff. Greater attention must be given to maintaining and developing these relationships.
A formal model of care could be developed and applied to the West Coast nursing service. The DHB has yet to formalise a clinical career pathway for rural nurses. Such a pathway would mean nurses are identified, coached, educated and socialised Adj. 1. socialised - under group or government control; "socialized ownership"; "socialized medicine"
liberal - tolerant of change; not bound by authoritarianism, orthodoxy, or tradition into advanced roles, including the nurse practitioner nurse practitioner
n. Abbr. NP
A registered nurse with special training for providing primary health care, including many tasks customarily performed by a physician. scope of practice.
Acknowledging the complex nature of the role, prospective RNS won't be appointed unless they hold an appropriate postgraduate qualification or have made substantial progress towards one. Director of nursing and midwifery midwifery (mĭd`wī'fərē), art of assisting at childbirth. The term midwife for centuries referred to a woman who was an overseer during the process of delivery. In ancient Greece and Rome, these women had some formal training. at the DHB, Jane O'Malley, continues to advocate nationally and internationally for the advancement of rural nursing as a specialist-generalist role.
The need for open dialogue with communities is important, given that nurses identified confusion about the role of the nurse in the communities in which they worked. There is inconsistency between how the community and the nurses view the role of the RNS. Expectations vary from community to community. Format, open dialogue about this is to be encouraged and could form part of the model of care process. A clearer understanding of the role of the nurse would benefit both the community and the RNS, as both sets of needs could be considered. RNS, in collaboration with other health team members, form the heart of health services health services Managed care The benefits covered under a health contract on the West Coast, beyond the towns and villages. A greater range of professional and personal supports is needed to maintain and grow the RNS workforce. The DHB must continue to work collaboratively with the Ministry of Health, nursing organisations, the Institute for rural Health, education providers, rural nurse scholars and West Coast communities to better understand rural nursing practice. A greater understanding will help advance rural nursing practice and retain the RNS service for the benefit of West Coast communities.
Michele Barber, RN, BA, is the nurse consultant at West Coast District Health Board. She completed this research as part of the requirement for a master of nursing and presented results at NZNO's primary health care nurses' conference in August this year.
(1) Bigbee, J.L. (1993) The uniqueness of rural nursing. Nursing Clinics of North America North America, third largest continent (1990 est. pop. 365,000,000), c.9,400,000 sq mi (24,346,000 sq km), the northern of the two continents of the Western Hemisphere. ; 1, 131-144.
(2) Bushy bush·y
adj. bush·i·er, bush·i·est
1. Overgrown with bushes.
2. Thick and shaggy: a bushy head of hair. , A. (2000) Orientation to nursing in the rural community. Thousand Oaks Thousand Oaks, residential city (1990 pop. 104,352), Ventura co., S Calif., in a farm area; inc. 1964. Avocados, citrus, vegetables, strawberries, and nursery products are grown. , CA: Sage.
(3) Jones, S., & Ross, J. (2000) Competency framework for developing rural nursing. Christchurch: Centre for Rural Health.
(4) Scharff, J. (1998) The distinctive nature and scope of rural nursing practice: Philosophical bases. In H. Lee (Ed.), Conceptual bases for rural nursing. New York New York, state, United States
New York, Middle Atlantic state of the United States. It is bordered by Vermont, Massachusetts, Connecticut, and the Atlantic Ocean (E), New Jersey and Pennsylvania (S), Lakes Erie and Ontario and the Canadian province of : Springer springer
a North American term commonly used to describe heifers close to term with their first calf. .
(5) Beech, J. (2007) Rural nurse says goodbye to Franz Josef Franz Josef, in certain Anglophone contexts rendered Francis Joseph may refer to the following people:
(6) Lee, H. (1998) Lack of anonymity. In H. Lee (Ed.), Conceptual basis for rural nursing. New York: Springer Publishing.
(7) Long, K. (1993) The concept or health: Rural perspectives. Nursing Clinics of North America; 28: 1, 123-130.
(8) Bailey, M. (1998) Outsider. In H. Lee (Ed.) Conceptual basis for rural nursing. New York: Springer Publishing.
(9) Smith, J. (2004) Australia's rural and remote health: A social justice perspective. Croyden: Tertiary Press.
(10) Wilkinson, D., & Blue, I. (2004) The new rural health. Melbourne: Oxford University Press.
(11) Rosenthal, K. (2006) The rural nursing generalist in the acute care setting: Flowing like a river. In H. Lee & C. Winters (Eds.) Rural nursing: Concepts, theory and practice. New York: Springer Publishing.
(12) Jones, S., & Ross, J. (2003) Describing your scope of practice: A resource for rural nurses. Christchurch: Centre for Rural Health.
(13) MacLeod, M., Kulig, J., Stewart, N., Pitablo, J., Banks, K., D'Arcy, C., et al. (2004). The nature of nursing practice in rural and remote Canada. http://ruralnursing.unbc.ca. (Canadian Health Services Research Health services research is the multidisciplinary field of scientific investigation that studies how social factors, financing systems, organizational structures and processes, health technologies, and personal behaviors affect access to health care, the quality and cost of health care, Foundation website). Retrieved 10/01/06.
(14) Brown, L., Eckhoff, M., Lindley, G., & Jones, S. (2002) A handbook for new end locum locum /lo·cum/ (lo´kum) [L.] place.
locum te´nens , locum te´nent a practitioner who temporarily takes the place of another. rural nurses. Ministry of Health: Centre for Rural Health. Gibb, H. (2002) Educating nurses for rural, clinical practice: Working and studying alone. In D. Wilkinson & I. Blue (Eds.) The new rural health. Melbourne: Oxford University Press.