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Remote area nurses consider their clinical knowledge and skills insufficient for the generalist scope of work required to provide primary healthcare in remote settings, a new study has found.

The gap supports classing remote area nursing, which requires unique skills different from typical practice settings, as a ‘specialist generalist role’ that requires further training and support on the job.

Edith Cowan University (ECU) researchers interviewed 24 remote area nurses working in primary healthcare clinics in communities with 150-1,500 residents across Australia. Thirteen of them were nurse practitioners and the remaining were registered nurses. Half of the participants had more than 10 years’ experience working in remote communities.

Remote area nurses help manage acute health issues, chronic illness, health promotion and emergency responses.

Led by Dr Kylie McCullough, a former remote area nurse, the study found nurses felt unprepared, both educationally and clinically, to work in remote environments, even if they had many years of nursing experience, and needed support and time to adapt to the environment.

Key issues identified were the need for cultural and clinical knowledge of health issues faced by people living in remote areas, particularly Aboriginal and Torres Strait Islander peoples, and the lack of experience in making critical decisions when working alone, or with less experienced co-workers.

“When you are working in ED, the final decisions aren’t really lying with you. The assessment skills … only go to a certain point and then the doctor takes over with any treatment…as a RAN, you take on a wider scope, you are certainly doing a greater number of assessments; …greater responsibility and decisions,” one participant said.

“All of a sudden you weren’t just being a nurse you were being a paramedic …police officer and whatever else comes with all that roadside stuff and so that was crazy and I had hardly cannulated anyone and all of a sudden we were cannulating people who were dying,” another participant reported.

“They’re asked to be more like GPs a lot of the time, and therefore need similar skills,” Dr McCullough explains.

“On top of that, quite often there are no police or paramedics in these communities; if there’s, say, a car crash, nurses hop into a LandCruiser and have to deal with these incidents all by themselves, with limited resources.

“It’s a lot different to being on a ward; we’re asking them to be ‘super nurses’ often without the proper preparation.”

Asking workers to step straight into remote area nursing without any experience in such an environment was asking too much, Dr McCullough argues.

“You end up with more people being hospitalised unnecessarily,” she says.

“Then they need the Royal Flying Doctor Service to transfer them to metropolitan hospitals and that adds more strain to the hospitals and greater stress for patients and their families.”

Heavy and stressful workloads are seeing nurses abandon remote posts, resulting in a constant cycle of new staff coming into communities, she adds…

“In [community] they’ve got six nurses and they probably turn over every two weeks, three weeks, four weeks they turn over. You know you get that cycle going for four years and you see a lot of nurses coming and going, the same with doctors and stuff like that and there’s very little continuity of care,” one participant said.

“This can erode the trust of the community in seeking healthcare,” Dr McCullough points out.

“It takes time to build trust.”

To improve the situation, Dr McCullough is calling for remote area nurses to get access to more education and support.

For example, she says one strategy could focus on training and hiring more nurse practitioners — who have studied a Masters level and have the authority to prescribe medications and order pathology tests, amongst other advanced skills.

Nurse practitioners who took part in the study reported they were better suited to meet the additional expectations and aspects of the role, such as health promotion.

Dr McCullough suggests greater flexibility for workers, such as fly-in fly-out rosters, and subsidising education and support initiatives could also help attract and keep more nurses in remote areas.

“Each community has its own set of challenges, so if someone has been there a while, they can better serve the public and better teach other nurses who come to work there,” Dr McCullough says.

“People in remote communities have poorer health outcomes in general and, like remote nurses, can be forgotten about as they’re out of sight and out of mind.

“Remote nurses are asked to do extraordinary things, so we need to support them.”

‘Nursing in a different world: Remote area nursing as a specialist-generalist practice area’ was published in The Australian Journal of Rural Health.