What makes rural nursing different? Rural health nursing doesn't just mean nursing in the country. It demands a range of professional and personal skills to ensure the nurse and the community feel safe.

WHAT MAKES rural health nursing so special, so distinct? Former director of the recently-closed Centre for Rural Health in Christchurch and rural health nursing lecturer Jean Ross, is well placed to know. From her childhood in rural Wales, through her training in a small district general hospital, to her charge position ten months after graduation, in a very isolated 25-bed hospital in Oban, Scotland, to her time as a rural nurse in north Canterbury, Ross has been closely connected to rural communities. These connections have instilled in her a passion for rural health nursing and a drive to explain the range of factors that combine to make this role distinctive, difficult, demanding and deeply rewarding.

Another pivotal nursing experience also served to deepen her commitment to rural communities and their health needs. She was running a 14-bed specialist haematology ward in Wales. There was no radiotherapy centre in Wales and patients had to go to England for treatment. "Not only did they have to leave their homes, their communities, they had to go to another country, another culture for treatment. And that was particularly hard on rural people."

An increasing business focus within the health service in the United Kingdom--"clinicians were answerable to administrators and treatments were being withheld because they were too expensive"--drove Ross to New Zealand in the early 1990s. In Oxford, north Canterbury, she was first introduced to the general practice system in New Zealand. She didn't like what she saw. "I was very confused and angry at a system where the patients had to pay and the rural practitioner was offering a good service but having to charge for it. And the practitioner was on call all the time."

After two years, she became the district and rural nurse in Oxford, with a strong rural health promotion focus. "The community knew what it wanted and asked for it. I facilitated cardiology, diabetes and asthma support groups, which the community set up. It was a very rewarding job."

During her time in Oxford, she, along with Akaroa GP Martin London, were invited by the then Southern Regional Health Authority (SRHA), to establish a centre to improve the quality of rural health care. The SRHA had money for quality improvement and the idea was to improve the quality of care through supporting rural health practitioners. So the Centre for Rural Health was established. (See box at right.) Research into the needs of rural practitioners, including the 64 rural health nurses in the SRHA area, led to the development of a tailor-made, post-graduate diploma for rural practitioners. Ross and London put that together in 1997, with the first diploma course in 1998. Attendance at a conference of rural GPs led to a contract with the Clinical Training Agency (CTA) to develop a national, inter-disciplinary diploma of rural health care with a 30 percent clinical component. That diploma ran for the first time in 1999 and has been running annually since. Once this year's diploma course is completed, it will not be offered again. (See box at right.)

So what can rural health nurses aspire to now? Ross sees the nurse practitioner role as offering opportunities. But she doesn't think the primary health care scope of practice encompasses all of rural health nurses' practice. "I don't think the primary health care scope of practice does justice to the context within which rural nurses practise. It doesn't encompass the totality of their scope of practice."

Living, working and interacting on a daily basis in the same environment as the people you care for, adds a whole new dimension to the practice of rural health nurses. "To be a rural health nurse you have to be able to function and deliver health care in the environment in which you live. The primary health care scope of practice doesn't encompass that. The rural health nurse is also the mother/father, the friend, the board of trustee member. But the rural community will view that person, first and foremost, as the nurse."

To be able to function effectively in that environment, the rural health nurse must build trust not just in the health centre, but in all interactions with the rural community. Ross estimates it can take up to three years for a newcomer to be accepted, and that can be "devastating" for the incoming nurse. "Everybody is watching you and your practice. Trust is built over time and if the nurse is not accepted s/he won't be able to function. The concepts of insider/outsider and new comer/old timer are very much part of rural communities. As well as professional expertise, the rural health nurse must have a range of personal attributes to he able to deliver effective care, and to survive within the community," Ross says.

What the unique and distinctive elements of rural health nursing are, is a subject Ross would like to pursue in her PhD studies. Her work as a rural health nurse, her role in developing the diploma, her contact with rural health nurses throughout the country, international research and her work with nursing researcher Shelley Jones, have identified a number of those distinctive aspects. An important one is managing the personal and professional self within a small community. "If you do one thing wrong, professionally or personally, the whole community knows about it. It's a bit like being a missionary, in that the work involves your whole being and that aspect needs to be contained within any scope of practice," Ross explains.

Inter-dependence with other health professionals, the need to be both a generalist and an expert, the very broad scope of practice, and that to be effective, the nurse must be very adaptable, are other distinct aspects of rural health nursing.

"The rural health nurses who do survive do so because of their personal attributes--adaptability, their ability to maintain confidentiality, their self reliance."

Rural health nurses must also understand that rural people have different cultures around living, working and their health beliefs. "Often health means being able to get up and go to work in the morning. That means they often leave things very late before contacting the nurse or doctor. They are more reliant on themselves and their family for health care. And the weather plays a huge part in their lives. If the hay's got be baled before it rains, that's the priority, not an appointment at the health clinic. So rural health nurses have to be opportunistic in terms of offering a health service. They've got to grab the chance when it comes," Ross says.

She says the wider profession has little understanding of the nature of rural health nursing and she would like to change that. She has energy for developing rural health nursing further. "Not all rural nurses will become nurse practitioners. Many will continue to work as experienced practitioners."

Possible areas for further development are in both undergraduate and post graduate education She will play a major role in doing this at Otago Polytechnic's School of Nursing, where she aims to develop a rural health nursing programme, starting later this year.

She also sees opportunities in working with district health board directors of nursing, who have a responsibility for primary health care through primary health organisations.

Whatever she does and wherever she works, Ross remains committed to rural communities and their health care. How rural nurses can best deliver care to those communities, while keeping themselves professionally and personally safe, remains her abiding passion.

Rural health diploma to end and centre closes

A TAILOR-made, inter-disciplinary rural health diploma, offered through Otago University's Christchurch School of Medicine, since 1998, will end this year. Changing needs, the development of the nurse practitioner role and different funding streams and requirements, have combined to end the diploma.

The diploma was developed in response to the education needs of rural health practitioners. It was originally developed and funded through the then Southern Regional Health Authority and subsequently by the Clinical Training Agency (CTA). Ninety students, 80 of them nurses, have completed the diploma, which included physical assessments, advanced paediatric life support and PRIME (primary response in medical emergencies).

Since the diploma was developed, the Nursing Council has developed its criteria for nurse practitioners. These include postgraduate education endorsed by the Nursing Council. The diploma has not been endorsed by Nursing Council. Some rural health nurses feel aggrieved their diploma does not fit the Council's post graduate education criteria. Ross explains the aim of the course, as originally established, was to upskill rural practitioners so they could function better in rural communities. "The diploma programme has met those aims. We were not contracted to run a course that was endorsed by Nursing Council. We were contracted to run a course which would improve rural health care through more highly skilled practitioners and the retention of those practitioners."

She said the the diploma met Nursing Council criteria for nurse practitioner competencies to some degree "but it was established in 1998 and it is now 2003".

Any post-graduate courses for nurses, to be funded by the CTA, must be offered through a school of nursing. Auckland University and Otago Polytechnic schools of nursing offer clinical masters programmes. Ross says she has been assured by both these schools that four diploma papers--half a masters degree--could be cross credited to a clinical masters, if they match their programmes.

She believes new post-graduate education opportunities will arise for rural health nurses "but that is not to undermine the diploma which is still current and its contents very valuable".

In a separate but linked development, the Centre for Rural Health, funded originally by the SRHA, then the Health Funding Authority and finally by the Ministry of Health, closed at the end of last year. The Ministry's desire for a national overview of what support and professional development is offered to rural practitioners, differing contracts fur the three current providers of such services, and a decision by the centre's contract holder have all led to the centre closure.

Ross felt "very let down, very sad" that all the work, commitment and collaboration she, London and others had contributed to the centre would not continue. But she now believes that, out of the upheaval, something new for rural nurses will emerge.