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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.

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Nursing in rural New Zealand 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 not only isolate the West Coast, they cut it off from the rest of the South Island. Within this context, rural nurse specialists (RNS) 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 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 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 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 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 description was a useful method for this small scale qualitative research, 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 that focused on demographics, 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) 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. 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.

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. This means the private lives of nurses are inextricably 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, 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 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 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 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, the West Coast DHB is challenged to review RNS' conditions of employment 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 into advanced roles, including the nurse practitioner 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 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 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.

References

(1) Bigbee, J.L. (1993) The uniqueness of rural nursing. Nursing Clinics of North America; 1, 131-144.

(2) Bushy, A. (2000) Orientation to nursing in the rural community. Thousand Oaks, 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: Springer.

(5) Beech, J. (2007) Rural nurse says goodbye to Franz Josef. West Coast Times, January 19.

(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 Foundation website). Retrieved 10/01/06.

(14) Brown, L., Eckhoff, M., Lindley, G., & Jones, S. (2002) A handbook for new end locum 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.
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Title Annotation:RESEARCH
Author:Barber, Michele
Publication:Kai Tiaki: Nursing New Zealand
Date:Nov 1, 2007
Words:2352
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