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The World Health Organisation has endorsed the role of nurses in implementing a primary health care model into traditional health services1. Rural nurses have a particularly important part to play in improving the health of their communities. Nurses have always been the largest group of professional providers within the rural sector in many countries including Australia2. Nursing is also a predominantly female workforce that complements the enormous health work done by women as carers in the community3. The professional and social role overlap of rural nurses is a recognised asset in delivering services within a rural community and strengthening its abilities to adapt to its own health needs4. Their knowledge of the community's cycle of events and economy, together with the fluidity of nursing role boundaries, are essential elements in strengthening the effectiveness and quality of the care system.
While it is difficult to make direct comparisons between the education, registration and regulation of nursing practice in different countries it is true to say that it would be difficult to provide health services without the presence of nurses in hospital and community settings. Yet in Australia, deteriorating occupational conditions have meant that nursing services can no longer be guaranteed to be in ready supply. Within the formal health care system, reforms have resulted in the restructuring of health services, downsizing of professional staff and increased use of non-qualified care givers. This together with the many career choices now open to women and the fact that nurses' skills and knowledge make them employable outside the health sector, means nurses continue to leave the system. Recruitment and retention of nurses in Australia has become a national concern.
There is no doubt that the general public value nursing very highly but when it comes to the policy level, nursing remains largely invisible. Despite the recent Australian policy document 'Healthy Horizons' stating that rural nursing is essential to improving the health of rural people5, the Australian Federal Health Department does not see the support of the nursing workforce as a priority, citing instead the responsibility of State governments as the major employers of nurses. Federal priorities clearly target the medical profession, as the significant amount of support funding allocated in the health budget attests. However most nurses, including rural nurses, work in public hospitals that are funded through Federal-State agreements. There are numerous problems, loopholes and discrepancies created by this funding formula, as found by the recent Australian Senate Review into Public Hospitals and many previous investigations over the years6. Staffing, quality, standards and accountability are but some of the concerns. Nurses may be employed in the public sector by the states, but the problems in state run services are of national significance for health care delivery. Some states have now begun to take action as evidenced by the Victorian review into recruitment and retention in nursing and the New South Wales Health report on nursing7,8. The necessity for mandated staffing ratios for nurses in public hospitals by the recent Blair Commission is a reflection of the measures now needed to redress the imbalance between the supply and demand for professional nursing expertise.
For rural nurses, the deteriorating conditions within the system that have caused so many to leave are more keenly felt. There is less staff to share the load and access to education and training is more difficult due to greater distances, cost, time and isolation. Career opportunities are scarce. Added to this are family responsibilities and life style issues surrounding shift work. Inflexible work hours, short-term contracts and fractional time appointments are a major factor in retention difficulties. Rural nurses frequently experience extended shifts and on call, no breaks during shifts and requests not to leave the locality during off duty hours. These issues have been recognised as pivotal in recruiting and retaining medical staff but are just as salient for the nursing workforce.
Rural nursing is different from that in the urban communities. Structures and solutions aimed at improving the urban services do not necessarily work in rural communities. Given the contextual nature of nursing it follows that rural nursing, staff-patient relationships and working practices differ significantly from their urban counterparts. There is much to be learnt from the nurse-led initiatives in sub-Saharan Africa as well as the rural areas of the USA and Canada9-11. The advanced practice and leadership roles that many nurses play in the delivery of health care in rural and remote areas of Australia continues to go largely unrecognised and under supported.
The need for high level policy commitment to provide services to rural and remote communities is being increasingly recognised in relation to medical practitioners. However, the need for ongoing reform of health policy to recognise the real value of rural and remote nursing in generating health, has progressed more slowly. Until all countries recognise this priority by developing national policy frameworks that incorporate a leadership role in health care delivery for rural nursing, recognising what they provide in terms of health gain, and cease to allow funding anachronisms to be an excuse, rural and remote nursing, as a valuable resource for health, will remain under utilised, and nurses will continue to vote with their feet by leaving the health system.
Julie Mahnken
Deakin University
Warrnambool, Australia
References
1. World Health Organisation. World Health Organisation European Strategy for Nursing and Midwifery Education for All. Madrid: World Health Organisation, 1997.
2. Keyzer D. In: G Hunt, P Wainwright (Eds). Expanding the role of the nurse. Oxford: Blackwell, 1994.
3. Davis C. Gender and the professional predicament in nursing. Buckingham: Open University Press, 1995.
4. Keyzer D, Hall J, Mahnken J. Gumtrees and Windmills. Research Report. Warranmbool, VIC: Deakin University, 1995.
5. Australian Health Ministers Conference. Healthy horizons. Canberra: Department Health and Aged Care, 1999.
6. Commonwealth of Australia. The Australian Senate Public Hospital Review. Canberra: AGPS, 2000.
7. Australian Industrial Relations Commission. Public Sector Agreement. (Online) 2000. Available from: http://www.anf.vic.asn.au/ (accessed 5 March 2000).
8. Knowles C. Our Committment - NSW Nursing Workforce. Sydney, NSW: NSW Health, 2000.
9. Akinsola H, Cuba N. Rural health provision in Botswana: the context of nursing practice and the expanded role of the nurse. In: Proceedings, 8th National Association for Australian Nurses Conference, February 2000; Toowoomba, Queensland, Australia.
10. Reel S Homegrown from the bottom up: caring for kids in coal country: a rural nursing approach. In: Proceedings, 8th National Association for Australian Nurses Conference. February 2000; Toowoomba, Queensland, Australia.
11. Ramus G, Smith G. Recruitment, retention and practice issues in nursing in rural Saskatchewin. In: Proceedings, 8th National Association for Australian Nurses Conference. February 2000; Toowoomba, Queensland, Australia.