CHAPTER 16. Dealing with distance
rural and remote area nursing
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• demonstrate an understanding of the impact of rural life on the health of rural Australians
• explain how the Australian rural and remote environment impacts upon the scope of practice of the nurse
• demonstrate an understanding of the differences between rural, remote area and metropolitan nursing
• describe the role and function of the rural and remote area nurse in Australia, and
• explain the issues currently impacting upon the practice role of the rural and remote area nurse.
RURAL AND REMOTE NURSING
This chapter provides an overview of the nature and different health status of rural and remote communities. In this chapter, the words ‘regional’, ‘rural’ and ‘remote’ refer to the 32% of Australians who live outside a major city (population equal to or greater than 250,000). There is no ‘one’ rural or remote community; rather, each community in Australia has a different economic base and different demographics that impact upon the health and health needs of rural and remote residents. Many rural researchers have argued that despite images of rural Australia as being a healthy place to live, rural Australians have poorer health than those living in larger population centres. While this health disadvantage is still acknowledged, current studies suggest that the effect is more from socioeconomic factors and risky occupations than from the rural environment itself.
A description of the role of both rural and remote area nurses will be provided, as well as an examination of the similarities and differences in their scope of practice. It will be demonstrated that the role of the rural and remote area nurse is different from that of the nurse employed in health facilities in major cities, and that the core difference is the generalist practice role, which can be from the novice to advanced practice level. This generalist role has resulted in the devaluing of the role of these nurses by other nurses working in more specialised fields.
Identified issues that impact on the scope of practice of rural and remote area nurses will be discussed—issues such as inadequate preparation for the role, lack of access to education and training, personal and professional isolation, and the lack of anonymity associated with working in small rural and remote towns. While some aspects of the role are highly valued by these nurses (e.g. the higher level of professional autonomy), the isolation and lack of preparation for the role often results in low retention rates, especially in the more remote communities (Dowd & Johnson 1995).
For those who stay in rural and remote practice, the work is both professionally and personally rewarding. To quote Western Australian nurse Andrew Cameron: ‘So the work is varied and on the whole, I find it tremendously rewarding’ (Cameron 2004).
Rural Australia is seen by most Australians as ‘the bush’. When visualising ‘the bush’, most Australians have images of wide-open spaces, clean air, a healthy lifestyle and primary production (agriculture, mining, forestry, fishing). They do not have images of poverty and of Indigenous populations with Third World health status. Despite this reality, the myths of ‘mateship’, ‘hardiness’, and people surviving through hard times caused by environmental factors (such as drought and flood) and/or economic factors (such as the value of the Australian dollar), still dominate the descriptions of rural Australia. To understand rural life today, however, requires the inclusion of images such as poverty, economic problems and underserviced healthcare needs.
The dominant image of rural Australia is one of being reliant on agriculture. Yet the 768 million hectares, which is the land area of Australia, have a great diversity of resources, opportunities and alternatives for future development (Lovett 1993). The key consideration in modern rural Australia is diversity. That is, no two rural areas are alike and some areas are more advantaged than others. For example, settlements that are in close proximity to capital cities, those on the coastal fringe, those with tourist potential, mining communities and the regional centres, are more likely to sustain growth and survive. In contrast, the more remote areas face a more tenuous and difficult future (Lovett 1993).
Approximately 32% of Australians live in rural or remote areas. Using the Australian Standard Geographical Classification, which classifies Australia’s population into five areas (major cites, inner regional, outer regional, remote and very remote), 29% of the 32% live in regional areas and only 3% live in remote areas (Australian Institute of Health and Welfare 2008a). When interpreting rural and remote health data, it should be remembered that in remote areas, a large proportion of the population is Indigenous (24% of the population in remote areas and 45% of the population in very remote areas) (Australian Institute of Health and Welfare 2008a). The Australian Institute of Health and Welfare (2008a:81) note: ‘this means that information about the health of Australians living in remote areas is often influenced by the generally poorer health status of the Indigenous population living in those areas’.
Rural and remote settlements do not have an homogenous economic base. Rather, their economic base ranges from mining, Indigenous settlements, coastal resorts, retirement communities, regional service centres and towns which could be considered to be commuter suburbs (as they are located on the periphery of a major city), to those dependent on agriculture, forestry and fishing (Frager et al 1997).
The composition of the population residing in rural areas of Australia has changed enormously over time. For example, since 1976, there has been a 60% decline in the number of farmers in their 20s. Instead of young people, those entering farming were more likely to choose farming as a mid-career option and therefore be aged 40 years or older. Additionally, younger people’s disinterest in farming has meant that many farmers stay longer into their later years. All of these changes have meant that the median age of a farmer has increased from 44 in 1981 to 50 in 2001 (Land and Water Australia 2004).
Farms have been subject to severe cost/price pressures, resulting in many farmers being asset rich and income poor (Rolley & Humphreys 1993). In the early twenty-first century, farm incomes have become diverse, with on-farm income comprising only a small proportion of earnings. The economic pressure on farmers has meant that farms have become larger. Thus, as smaller farms are merged to make larger economic units, the farming population has declined (Land and Water Australia 2004). Additionally, many family-owned farms have been replaced by corporate farming. In the late twentieth century, the rural landscape had changed considerably with only one in ten people in the non-metropolitan workforce employed in agriculture, and with many people living in retirement in rural coastal areas (Australian Institute of Health and Welfare 2004a).
Rural and remote Australians have some characteristics that are quite different from Australians living in major cities. For example, they:
• have larger families
• are less likely to be aged between 15 and 34 years
• are less likely to be one-parent families
• are more likely to own a car
• are more likely to have both partners of the marriage in employment, and
• are more likely to be employers rather than employees (Australian Institute of Health and Welfare 2004a).
It must be remembered that rural Australia is composed of much more activity than agricultural pursuits and that the income generated by rural women is a vital part of the rural landscape. In a 2004 report on Women in business in rural and remote Australia, it was found that the income derived by regional businesswomen around Australia was diverse and generated income in the order of $1.2 billion per annum (Houghton & Strong 2004). The authors noted that regional women ran businesses which ranged from ‘bed and breakfasts and traditional “country craft” business to business in professional and health services, education, manufacturing, and personal and business services’ (Houghton & Strong 2004:2). In some cases, the income provided much-needed off-farm income, while in other cases, the women lived in town and had no link with agriculture (Houghton & Strong 2004).
While much is made about the isolation of rural communities (and isolation from services will be the focus later in this chapter), some argue that communities are far less isolated than they were in the past. Epps and Sorensen (1993) stated that in the 1970s a typical rural life was one where incomes were largely dependent on seasonal conditions and fluctuations of commodity prices, housing was cheap and functional, and food prices were high. In addition, less emphasis was placed on educational attainment than today, services were fewer and of poorer quality than those of larger cities because of low population density and insufficient demand to make delivery of services worthwhile, and many rural communities experienced outmigration of the young and energetic. People were concerned about the weather, isolation and road conditions, had a strong work ethic and viewed impersonal city life with suspicion (Bessant 1980).
It is argued that rural Australia has been transformed since the 1970s in that technology has reduced the sense of isolation, deregulation of transport has facilitated overnight parcel deliveries to many rural areas, people can travel further by road to obtain goods and services, and larger regional centres often have cultural visits by national and international artists (Epps and Sorensen, 1993 and Rolley and Humphreys, 1993).
Recognising that the face of rural Australia is constantly changing, and that there is no one standard rural town or area, it is time now to examine the claims that rural and remote Australia is a healthy place to live.
RURAL AUSTRALIA: A HEALTHY PLACE TO LIVE?
The myth of rural Australia as a healthy place to live seems to have dated from the nineteenth century and it appears that, in comparison to industrialised and urbanised Europe, it may have been so (Walmsley & Sorensen 1988). Rural people have been reported to have a more self-reliant attitude to health (Lovett 1993). They are renowned for their independence, resourcefulness, capacity for hard work, stoicism in the face of adversity, generosity and community-mindedness (Rolley & Humphreys 1993).
In the late 1990s and early 2000s, there have been several publications focusing on the health of rural and remote Australians (e.g. Strong et al., 1998 and Australian Institute of Health and Welfare (AIHW), 2004a). The major findings of these reports suggested that rural and remote Australians have considerable differences in morbidity and mortality rates to those Australians living in major cities. These studies have been confirmed by recent publications (Australian Institute of Health and Welfare 2008a), which suggest that:
• life expectancy decreases with increasing remoteness
• people living in rural and remote areas are more likely to have certain chronic diseases (e.g. cancer, depression, diabetes, arthritis) than people living in major cities
• children tend to have more decayed, missing or filled teeth
• mortality rates are higher, the main contributions being coronary heart disease, ‘other’ circulatory disease and motor vehicle accidents; additionally, for people less than 65 years of age, injury (e.g. motor vehicle accidents and suicide) are notable contributors to deaths, particularly among males
• perinatal death rates increase with remoteness
• rural and remote people are more likely to smoke
• the intake of other drugs and alcohol is higher with consumption of alcohol increasing with remoteness, and
• these populations are more likely to be overweight or obese and report sedentary behaviour.
The causes of this health disparity are linked strongly to the socioeconomic and environment factors impacting on rural and remote Australians (Australian Institute of Health and Welfare (AIHW), 2008a and Smith et al., 2008). An important factor within the environment is the distance that rural people are forced to travel to access equivalent health services taken for granted by people living in larger population centres (Smith et al 2008).
Socioeconomic disadvantage is now higher in rural districts than in major cities and is a significant variable in terms of rural health. The factors that influence this disadvantage include: high unemployment rates in rural and remote areas; decreased education opportunities; a higher proportion of unskilled labour in the workforce; and, with the exception of some remote mining communities, a lower family income (Australian Institute of Health and Welfare (AIHW), 2008a and Frager et al., 1997). A number of studies have found links between low socioeconomic status and the health of the individual in rural areas (Australian Institute of Health and Welfare (AIHW), 2008a, Frager et al., 1997, Smith et al., 2008 and Strong et al., 1998). Smith et al (2008:59) note that ‘much of the variation between rural and urban health status can be explained by socioeconomic factors affecting the use of health services’.
Use of health services: problems posed by distance
Rural Australia is characterised by low population densities and varying distances between towns (Strong et al 1998). These low population densities are of ‘critical importance in understanding problems of service provision’ (Humphreys & Rolley 1991:23). Rural people ‘in need’ are more dispersed and isolated in their distribution than city residents in major cities, and this makes the provision of even basic services extremely expensive (Rolley & Humphreys 1993).
It is well documented that accessibility is the main issue for rural residents (Australian Institute of Health and Welfare (AIHW), 2004a, Humphreys and Rolley, 1991, Macklin, 1991 and Smith et al., 2008). This lack of accessibility is caused by remoteness. Remoteness has been defined as:
… access to a range of services, some of which are available in smaller and others in larger centres: the remoteness of a location can thus be measured in terms of how far one has to travel to centres of various sizes (Department of Health and Aged Care and Geographical Information Systems Classification of Australia 2001, cited in Australian Institute of Health and Welfare 2004a:2).
Populations in Australia (and thus the health status of these populations) are now reported on according to one of three ‘remoteness classifications’. However, all of these classifications have limitations, and the readers of this chapter are referred to the discussion about these strengths and weaknesses as outlined in ‘Rural, regional and remote health: a guide to remoteness classifications’ (Australian Institute of Health and Welfare 2004a).
Accepting that rural and remote Australians are affected by remoteness, and despite Macklin’s (1991) statement that universal coverage and equity of access ‘to the healthcare system are two important principles which are widely accepted’ (Macklin 1991:5), in rural and remote areas of Australia, the reality is that the majority of residents do not have access to the range of services available in major cities. The barriers of access to health services by the rural and remote population have been identified as: lack of healthcare professionals; cost and limited access to specific services; and lack of culturally acceptable services.
Lack of healthcare professionals
There is wide agreement that rural and remote Australian communities are underserved by appropriately trained health professionals. Additionally, there is evidence that urban-background medical practitioners are less likely to remain in rural practice for more than 3–5 years. This contrasts with medical practitioners with a rural background, who are more likely to choose a rural career and remain in practice for longer (Hays et al 1997). Further, in many of the more remote areas of Australia, communities are unable to attract a medical practitioner and are dependent upon rural and remote area nurses to provide their healthcare (Macklin 1992). The shortage of rural registered nurses is also now impacting on healthcare delivery in rural and remote areas (Australian Institute of Health and Welfare 2004a).
The problem of recruitment and retention of medical practitioners to rural areas has been the subject of several discussion papers (e.g. ‘The future of general practice’, Macklin 1992). Schemes focusing primarily on medical practitioner recruitment and retention such as the Rural Incentive Program (Hays et al 1997), the Rural Clinical Schools (Australian Government 2004b) and the University Departments of Rural Health (Humphreys et al 2000) have been introduced to address this problem.
The same level of attention has not, to date, been given to the issues of the recruitment and retention of other health professionals such as nurses and allied health, mainly because medical practitioners are seen as ‘employees’ of the Australian Government (through Medicare reimbursement), whereas nurses and allied health professionals are normally employees of state or territory governments (Hegney 1996). However, as the shortage of nurses has increased, the state/territory governments, the Australian Government and private enterprise have begun to offer incentive programs for nurses. For example, the Australian Government now offers the aged care nursing scholarship scheme, as well as the rural and remote nurse scholarship program, which provides support for undergraduate, reentry, upskilling, postgraduate and conference scholarships (Australian Government, 2004 and Australian Government, 2004). Examples of state and territory government scholarships include:
• the New South Wales Nursing and Midwifery Innovation Scholarships: www.health.nsw.gov.au/nursing/scholar.html
• the Australian Rotary Health Research Fund: Parnell Rural and Remote Nursing Scholarship: www.arhrf.org.au/main.asp?pageName=Rural%20Medical%and%20Nursing
• the Queensland Health Rural Scholarship Scheme: www.health.qld.gov.au/orh/qhrss/default.asp
Since 1991, when the first national rural health conference was held in Toowoomba, Queensland, there has been a plethora of rural health organisations. For example, the National Rural Health Alliance (NRHA), which is an organisation comprised of key professional and consumer rural organisations, is now responsible for most of the lobbying to governments for adequate rural health policies. Professional organisations, such as the Rural Doctors’ Association of Australia (RDAA), the Services for Australian Rural and Remote Allied Health (SARRAH), the Council of Remote Area Nurses of Australia (CRANA), the Isolated Children’s Parents Association (ICPA), and the Country Women’s Association of Australia (CWA), are all member bodies of the NRHA. Despite the work of these organisations, in 2008 there was still a shortage of Australian-born medical practitioners, nurses and allied health professionals in rural and remote Australia. This lack of a ‘stable, efficient and well-educated workforce’ directly impacts upon the viability of rural health services (Kenny & Duckett 2003).
Cost and limited access to specific services
Several authors, in their examination of the health resources available to rural and remote residents, have noted that:
• nurses provide a higher proportion of healthcare in rural and remote Australia than in metropolitan Australia (Strong et al 1998)
• nursing home beds are less likely to be available as remoteness increases (Australian Institute of Health and Welfare (AIHW), 2008a and Strong et al., 1998)
• Medicare data indicate that people living in rural and remote zones use less services than those living in major cities (Australian Institute of Health and Welfare (AIHW), 2008a and Strong et al., 1998), and
• the number of doctors (including medical specialists) and pharmacists declines as an area becomes more remote (Australian Institute of Health and Welfare (AIHW), 2008a and Strong et al., 1998).
People in rural areas therefore, while experiencing increasing levels of poverty, have to face increased costs of travel and accommodation should they require anything other than basic primary care services. While schemes such as the Isolated Patients’ Travel Assistance Scheme have been available for some time, patients usually have to pay the costs up-front and seek reimbursement later. This can be problematic if the rural person was unaware of their entitlement or wishes to claim after they have sought treatment (McGrath et al 1999). The financial and personal cost of travel for treatment in a major centre does mean that some rural people will either choose more radical initial surgery options (e.g. women will choose to have a mastectomy for breast cancer rather than radiotherapy and chemotherapy) or they will delay treatment until it can no longer be avoided (Hegney et al., 2005a, Humphreys and Rolley, 1993 and McGrath et al., 1999). A Senate Inquiry into patient travel schemes in 2007 (Parliament of Australia, Senate 2007) made 16 recommendations, including the establishment of a taskforce to drive the development of national standards to ensure equity of access to medical services.
One way to overcome the need to travel to services is to bring the service to the population. One such method is the use of telehealth services. These services were initiated in the 1990s by leaders such as Professor Peter Yellowlea who provided psychiatric clinics using telehealth services. Australian telehealth service provision appeared to stall in the late 1990s and early 2000s. However, there are some excellent examples of telehealth services currently under trial. For example, Professor Len Gray, a geriatrician located at the Princess Alexander Hospital in Brisbane, provides a telehealth service to the rehabilitation unit at the Toowoomba Health Service (approximately 130 kilometres west of Brisbane, Queensland). The service provision overcomes the lack of availability of a geriatrician in Toowoomba, and provides support to both patients and staff of the service in Toowoomba.