The experience of general nurses in rural Australian emergency departments
Article Outline
- Abstract
- Introduction
- Methods
- Results and findings
- Discussion
- Conclusion
- Conflict of interest statement
- Acknowledgment
- References
- Copyright
Abstract
Australia is a geographically unique country with large areas classed as rural. Nurses providing emergency care in rural hospitals face a number of challenges, with rural communities expecting multi-skilled nurses, prepared for a wide range of unannounced situations. Using a mixed method approach, involving questionnaires and focus groups, the study was undertaken in two rural health services in Victoria, Australia. The aim was to explore the experiences of general nurses working in rural hospital settings, with regards to their emergency department responsibilities. The findings indicate that nurses lacked confidence, which they attributed to the sporadic nature of working in the area and the diversity of people who presented. A resultant ‘skills rusting’ was described and nurses identified the need to be a diverse ‘specialist’. Some lack of confidence, particularly in the mental health area, was related to feelings of isolation and lack of context specific education and training. While some excellent emergency specific education and training is available for rural nurses, access is limited by a multitude of constraints. This study found there is an urgent need for local emergency education and training; with nurses showing a strong preference for ongoing professional development incorporating scenario based and context specific education.
Keywords: Rural, Emergency department, Professional development
Introduction
Large areas of Australia are characterised by rurality, geographic isolation, socioeconomic inequality, inequitable distribution of resources and extreme climatic conditions (Smith et al., 2008, p.159). Rural Australians have poorer health status and outcomes compared to metropolitan dwellers, in part, due to a higher proportion of older people living in rural areas, higher levels of disabilities and chronic conditions, higher likelihood of injury and lack of access to health services (Victorian Government Department of Health, 2009, Gregory, 2010). There is a looming crisis in Australian health services as the population ages and the available workforce contracts. Sustainability of services is threatened by workforce shortages and inequitable funding (Gregory, 2010, McGrail and Humphreys, 2009a, Sullivan et al., 2008).
Rural nurses account for 60% of the rural health workforce but their role receives little attention in the broader context of Australian health service delivery (Sullivan et al., 2008). Studies that have examined rural nursing claim that rural nurses should be considered specialists as rural practice is challenging and diverse (Endacott and Westley, 2006, Fitzgerald, 2008). In 2006, Endacott and Westley reported that rural nurses need to be
‘prepared and equipped with the knowledge and skills to deal with a wide range of unannounced clinical situations, such as treating car accident victims, farm accidents, expectant mothers, mental illness, chest pain and acute conditions as well as performing administration roles’ (Endacott and Westley, 2006, p.277).
International researchers from Australia, the United Kingdom (UK), Canada, and the United States (US) suggest that rural nurses often work outside of their professional scope of practice, and cite isolation and maintaining professional competency as their greatest difficulty (Manahan and Lavoie, 2008, Montour et al., 2009, O’Meara et al., 2002, Stewart et al., 2005).
The rural Victorian context
In Victoria, registered nurses provide the core staffing in most rural hospitals and onsite medical practitioners are rare (Australian Bureau of Statistics, 2010, Kenny and Duckett, 2004, Sullivan et al., 2008). Consequently, in most situations registered nurses are required to provide first line management in the absence of medical staff, particularly in hospital emergency departments.
Rural medical shortages have led to increased attendances to hospital emergency departments (Australian Health Workforce Advisory Committee, 2006, Callen et al., 2008). This creates pressure for ‘generalist’ nurses to competently act in an emergency nursing capacity. The complexity for the generalist nurse is compounded by the fact that they are often required to independently fulfil their role (Greenhill et al., 2008, Montour et al., 2009, Sullivan et al., 2008).
Little is known about general nurses who work in rural hospital emergency departments. Understanding their role and continuing education needs is important, particularly considering medical shortages, nurse retention issues and the fact that many rural health services are in effect nurse led services (Fitzgerald, 2008, Hegney et al., 2010, Manahan and Lavoie, 2008, Mills, 2009, Sullivan et al., 2008). In 2009, the Victorian Department of Health reinforced the need to support and educate rural nurses:
“With the challenges faced by rural health services in maintaining access to medical practitioners, services must ensure nurses are well trained and supported …so that, where appropriate, health care needs of people presenting in an emergency can be met without on-site medical support” (Victorian Government Department of Health, 2009, p.39).
However, to ensure that education and support reflects the needs of this group, greater understanding of their role is required. This study aimed to explore the experiences of general nurses working in rural hospital settings with regards to their emergency department responsibilities.
Methods
In order to meet the study aim, a two stage, mixed method approach was developed as it was contented that qualitative and quantitative aspects of the study could be both complementary and integrated (Bryman, 2007). The stage one questionnaire was adapted from a broader questionnaire developed, pilot tested and successfully used in a recent Australian study (Kenny et al., 2007). The 16 questions were grouped into three sections; demographic information, emergency skills confidence and continuing education. Areas such as frequency of working in the emergency area and perceived confidence and support were explored. The questionnaire included five point likert scales and open-ended fields.
Focus groups were utilised in the second stage to provide a richer understanding of participants’ experiences (Freeman, 2006, p.491). The focus group schedule was framed directly from questionnaire results and included seven major questions and prompts related to the ageing rural nursing workforce, confidence in attending emergency presentations, continuing education needs and the overall experience of being a nurse in this setting.
Sample, recruitment and ethics
The sample for this study consisted of all nurses (n120) from two rural health services that had tended emergency department clients in the previous twelve months. Nurses that met this criterion were identified by nursing management, and anonymous questionnaires were distributed by management through staff mail and returned directly to the researchers by mail. The focus groups were advertised internally using a poster. Both activities were voluntary.
Ethical approval was obtained from La Trobe University’s Faculty of Health Sciences Ethics Committee.
Data collection
The questionnaire response rate was 44%, with 53 questionnaires completed. Two focus groups were conducted, attracting five participants for the first and twelve for the second. Video conferencing was utilised to enable participation across wide geographic areas. Each lasted approximately 1 h. The focus groups were facilitated by two researchers, with the first asking the majority of questions (TK) and the second providing input, observations and feedback during and after the group.
Data analysis
Descriptive statistics were generated from the questionnaires, utilising the software program SPSS. The focus groups were audio recorded, transcribed verbatim and transcripts were independently analysed by three researchers (TK AK TM), using the NVivo program. This involved the preliminary identification of basic themes, organising themes and a global theme (Attride-Stirling, 2001). The researchers came together to develop consensus and consider the results/findings from the questionnaire and focus groups. Again using Attride-Stirling’s (2001) approach, three main themes were developed; rural workforce composition, rural generalist vs. emergency specialist, and promoting continuing education. The global theme identified was building capacity for rural emergency nursing. The development of the network is illustrated at Fig. 1.
Fig. 1
The constructed thematic network.
Combining quantitative results and qualitative findings were important in avoiding the common error of mixed method studies where the qualitative and quantitative components are treated as separate domains (Bryman, 2007, p.9).
Results and findings
Rural workforce composition
Of those who completed the questionnaire, 73% were aged 45 or older, with a small number aged above 60, and one respondent aged over 70. Most respondents indicated that they were trained in the hospital apprentice style of training (78%). The majority of respondents worked part time (75%), with 65% stating that they worked less than five shifts per fortnight. Overall, emergency skills confidence scales completed by respondents showed that 47% were less than confident working in the emergency setting, 91% stated they were less than confident with mental health presentations and similarly 92% stated they were less than confident with presentations relating to drug and alcohol use. Those who professed confidence related it directly to area specific training and experience. Open-ended responses related to continuing education, with most indicating accessibility issues rather than the quality of the education available.
Rural generalist vs. emergency specialist
Focus group participants related that “not many people want to work in ED [emergency department]”, relating it to lack of confidence, combined with the fear of the unknown. The ‘unknown’ extended beyond presentations to the lack of actual and potential support. Apart from having only one or two other staff onsite; difficulties related to some doctors who do not like to be called in relation to emergency presentations:
“The most difficult decision in a rural emergency department do I get the doctor…? They don’t want to contact the doctor unnecessarily because they get crabby”.
Other participants concurred:
“Some doctors you wouldn’t mind ringing 100 times but other doctors you will sweat over. Do I have to ring or can I avoid ringing or should I ring or should I not …It’s another pressure isn’t it?”
Subsequently participants described how difficult it is working in the emergency context and subconsciously feeling isolated. This was perceived as a barrier to building confidence and impacts on the willingness of staff to work in the area.
The expectation of ‘worst case scenarios’ was described as a major issue that impacted on confidence. However, another participant explained this is rarely the case:
‘True…resuscitation scenarios are around 3–5% [of total emergency presentations]’.
The common misconception of ‘worst case scenario’ was extended to describe how a patient presenting via the emergency department was often deemed more ‘scary’ to deal with than a similar patient who might need the same care but as an inpatient.
Both focus groups strongly related lack of confidence to infrequent emergency skills exposure and subsequent ‘skills rusting’ which was seen to ‘weigh heavily on everybody’. The infrequency of exposure was due, in part, to the majority being part time staff that ‘might only go there once a month’. This meant that lack of confidence in assessment skills was further compounded by lack of regular practice.
Questionnaire results indicated that nurses especially lacked confidence in presentations involving mental health and/or drugs and alcohol. All focus group participants agreed these areas, as well as cardiac and paediatric presentations, were common causes of concern. Participants explained that lack of confidence and skill in mental health was related to a lack of foundational knowledge.
‘A lot of the older nursing staff didn’t have any training in mental health at all. The broken body was something that was drummed into us but not necessarily the broken sprit so it’s really an area that you don’t feel that you have any comfort zone at all. So immediately someone comes in and they’re talking about their depression, it sets off a sense in the nurse that already we’re in trouble just by the sheer nature of what it is. It might turn out to be nothing but the anxiety level goes up straight away’.
Most lack of confidence involving presentations related to drugs and/or alcohol was related to fear of aggression and lack of ready back up, with the nearest police presence for one location 4 h away.
Nurses from both focus groups talked about lack of confidence in working in the emergency area being attributed to the fear of litigation, ‘[there is] so much anxiety about absolutely doing the right thing 100% of the time’. It was perceived that this fear was heightened because of exaggeration by the media highlighting infrequent cases. Specifically how this impacts on the confidence of nurses was illustrated by one participant who explained that nurses were less likely to rely on their own judgement with the threat of litigation:
‘[nurses] are perhaps not as comfortable with [regulatory compliance] now and would tend to be wanting to call the doctor [and] not rely on their judgment or skills quite as much as they used to for fear of making a wrong decision’.
Promoting continuing education
The topic of continuing education was discussed at length in both groups. The suggestion of metropolitan rotations to address continuing education deficits made on one returned questionnaire was met with considerable resistance from all focus group participants. Staff explained that metropolitan placements had been tried and had proven a waste of time. The environment, equipment and professional culture of metropolitan settings were seen as too different for any valuable learning to occur:
‘It’s different to how we operate here…It is definitely situation specific. We can work quite comfortably [in the rural environment] but take us down to the [other larger hospitals] and put us in an emergency department and I will freely admit I would be like a drowning duck’.
In general, the experience of metropolitan placements had been that the placements were too short for nurses to be accepted into the work place culture and they were treated with professional disrespect by nurses from metropolitan areas.
‘There’s no point spending two weeks because if we go down to [metro] and do two weeks placement in an ED we will want to have a good two weeks. We don’t want to have to be following someone around… And it’s how you’re treated because…if you go down to a metropolitan hospital [you are] treated like the dumbest nurse you know because [you are] from the country’.
When asked what kind of continuing education would best suit their needs, participants stated that continuing education needed to be specific to the rural context. Those few nurses, who had attended the Remote Area Nurse (RAN) course (which is specific to the rural and remote Australian setting), stated it was ‘one of the best things we’ve seen in the last few years’. With other participants agreeing; ‘Yes it was excellent, amazing’. Participants reiterated that any education for rural nurses should take into account:
‘[the rural] environment and how we tackle it… we just do things differently here without doctors being here all the time’.
Participants also explained that their education needs differed from nurses in different settings. Where nurses in metropolitan settings are more likely to seek education in specific areas:
“the rural nurse looks for education on everything because he or she’s a jack of all trades and master of none”.
While participants were well aware of the emergency specific courses that were available to them, they stated that the relatively large costs involved were prohibitive. Participants lamented that not all state governments supported the continuing education of nurses, with the Queensland government’s professional development financial assistance and leave entitlements touted as ideal. This clear support of continuing education for nurses meant the Queensland government was seen as ‘really supportive of their nursing staff’.
When asked about increasing the confidence of rural nurses in the emergency area, the response was for increased opportunity for education specific to the area. The suggestion of 24 h medical presence at the hospital was dismissed as unrealistic. Overall, it was felt that if nurses are given adequate preparation and ongoing support, the capacity for rural nurses to work comfortably in the rural emergency setting would be greatly improved:
“[Rural nursing] demands more of you, it demands different things of you, it gives you a range of anxieties that you don’t have [in the city]… it is very challenging. If you rise to that challenge, you know it does make you feel good that you’ve achieved, the fact that you rose to the challenge”.
Finally, despite the apparent challenges of rural nursing, participants from both stages of the study stated that they enjoy great job satisfaction and all of those things that make rural nursing unique are ‘just part of it all’. Participants also agreed, however, that there is inadequate professional (which includes monetary) recognition for rural nurses:
“Nurses take a lot of responsibility and make decisions that perhaps nurses in city/larger hospitals with a staffed ED would not and I think this is not recognised by the profession as it should be”.
Discussion
Collectively, the results of this study painted a picture of an ageing, predominantly female rural nursing workforce, the majority of which work part time and are set to retire in the next 10 years. Nursing shortages in rural and remote Australia are now classed as ‘critical’ (Australian Trades, 2008, Kenny, 2009). This is coupled with the current decline in the working age population, predicted to impact on Victoria in particular; where it will reach zero growth by 2012 (Sullivan et al., 2008). Studies by the Productivity Commission demonstrate that rural and remote areas will feel the impact of workforce shortages sooner, and more acutely, than in metropolitan areas (Australian Government Productivity Commission, 2005). This has prompted a growing concern for the sustainability of rural health services, particularly considering ongoing difficulties in securing a medical presence (McGrail and Humphreys, 2009b).
Those elements that make rural nursing challenging were confirmed by this study. These factors have been identified in other studies internationally and include workforce shortages, geographical isolation, limited back-up, need for a broad skill base, and difficulties accessing training and education (Manahan and Lavoie, 2008, Montour et al., 2009, O’Meara et al., 2002, Stewart et al., 2005). Nurses lacked the confidence to attend to clients in the emergency setting, mostly due to skills rusting. The level of expertise required for rural practice can take years to achieve and while most of the nurses in this study had worked in the area for many years; competence is something that comes with repeated exposure, which is difficult to achieve in the diverse setting (Nayda and Cheri, 2008). When continuing education does take place, it is often so long before the skills are utilised in the work place the practitioners have lost confidence to use them or the skills have been forgotten (O’Meara et al., 2002).
The findings in relation to lack of confidence with mental health skills are supported by other studies that report rural nurses have inadequate skills and limited knowledge of mental health problems (Clark et al., 2005). This finding was reported from a Canadian study (Haggarty et al., 2010) that prompted the development of a rural and isolated toolkit to support mental health care. The Canadian study supports the lack of quality mental health services in rural areas and stresses the need to support rural clinicians.
Emergency specific continuing education is available, however, Hegney (2010), found nurses in rural areas face significant barriers in accessing continuing education compared to their metropolitan counterparts. As identified in this study, a number of international studies consistently cite lack of finance; time, study leave, back fill availability, distance, inflexible learning environments and unrealistic expectations relating to clinical practice as major barriers (Hegney et al., 2010, Montour et al., 2009). There is evidence to show that nurses are using leave entitlements, such as long service leave and annual leave in order to attend courses and recommendations include scholarships and financial support (Australian Nursing Federation, 2008).
A number of different approaches to addressing issues related to rural continuing education should be considered. Health services need to actively support their staff to maintain their skills. This includes providing locally available education, and support to release staff to gain education and experience in other places. There is a need for more continuing education opportunities, including conferences, to be available in rural areas (Hegney et al., 2010). Continuing education does not necessarily always need to be face to face and other avenues should be considered. A recent study found that online, enquiry based modules used for continuing education were very successful with staff, encouraging deeper learning through reflective practice. This method increased confidence and problem solving skills (Kirwin and Adams, 2009).
This study supports other researchers who argue nurses would access more continuing education if they were financially supported (Hegney et al., 2010). There are calls for increased governmental funding for rural health services. At this time, the funding priorities are directed at metropolitan services, however, Gregory (2010, p.48) from the Australian National Rural Health Alliance states that funding needs to be matched by investment into rural regions.
Conclusion
Whilst it is clear that the rural health workforce is in crisis and there is no easy fix, adequately supporting nurses, is obviously of crucial importance to ensure sustainability. This study has shown that rural nurses work in difficult circumstances, without complaint and display a good deal of stoicism. The study has shown, however, that issues with confidence in emergency nursing skills might be mitigated with adequate funding and locally available, context specific continuing education and professional development.
Conflict of interest statement
None declared.
Acknowledgment
This paper was presented at NETNEP 2010 Conference.
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PII: S1471-5953(11)00092-8
doi:10.1016/j.nepr.2011.05.001
© 2011 Elsevier Ltd. All rights reserved.
