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The Practice of Registered Nurses in Rural and Remote Areas of Australia: Case Study Research

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The Practice of Registered Nurses in Rural and Remote Areas of Australia: Case Study Research The practice of Registered Nurses in rural and remote areas of Australia: Case study research Nicola Lisa Whiteing BSc (Hons), MSc (Distinction), PGDip HE, RN, ANP, RNT A thesis submitted in fulfilment of the requirements for the degree of Doctor of Philosophy Central Queensland University April 2019 Abstract This study aimed to delineate the roles and responsibilities of Registered Nurses (RNs) working in rural and remote areas of Australia and to explore the clinical and educational preparation required to fulfil such roles and responsibilitie . Whilst much research exists surrounding rural and remote nursing, few studies have looked in depth at the roles and responsibilities and necessary preparation for rural and remote nursing. Indeed, much of the literature encompasses rural and remote nurse data within the wider metropolitan workforce. There is limited research which clearly defines the rural and remote populations being studied. This study, however, clearly delineates those nurses working in rural and remote locations by the Australian Standard Geographical Classification – Remote Areas system (ASGC-RA). It is known that nursing is facing a workforce crisis with many nurses due to retire in the next ten to 15 years. It is also known that this is worse in rural and remote areas in which the average age of the workforce is higher and there are issues with recruitment and retention of nurses. Thus, there is a need to understand the practice of RNs, preparation for the role and challenges that need to be addressed in order that such workforce issues can be addressed. The study was carried out utilising Yin’s case study research design. A multiple embedded case study design was selected as appropriate to explore and explain in greater detail the practice of Registered Nurses. The study was undertaken in two States of Australia, Queensland (QLD) and New South Wales (NSW). The philosophical paradigm in which the study is situated is that of social constructivism in which there is a belief that knowledge is generated through experiences and interactions with the social world. The study comprised three phases of data collection and analysis. The first, a content analysis of documents relating to the context of nursing and more specifically rural and i remote nursing, second, a content analysis of an online questionnaire and third, a thematic analysis of semi-structured interviews revealing five major themes. Data from the three phases were converged through pattern matching and empirical propositions were derived from the data. Alongside many replicated findings the study also generated new findings. Major new findings included the influence of expectation on practice, perceived inadequate managerial understanding and support of the rural and remote RN role, an inability to fulfil the Primary Health Care (PHC) model of practice, the level of experience necessary to work in rural and remote areas, lack of preparation in mental health and maternity, an inability to access professional development, limited collaboration and networking opportunities, and misperceptions held by metropolitan staff. The Theory of Cognitive Dissonance was applied to the findings to explain the practice of the RN working in rural and remote areas. Through this theory it is evident that a number of implications and recommendations can be proposed in the areas of practice, organisation, education, policy and future research. ii Personal acknowledgments I’ve never liked the analogy of life being like a roller coaster but in considering this doctoral journey it is somewhat fitting. My first considerations of undertaking a PhD occurred having just returned from maternity leave after the birth of my first child Jack ten years ago. Little did I know then that that first conversation would lead to beginning a PhD, having my second child Amelia, moving to the other side of the world, starting a new PhD topic and having my third child Hannah, having numerous changes to my supervisory team, all whilst working full-time! To say it has been a challenge is an understatement and as I sit here writing this, I find it hard to believe that I have finally got to where I am. Of course, this journey was one that could never have been completed alone and I am forever grateful to all my family, friends and colleagues that have offered support, words of wisdom, refreshments and a shoulder to cry on. Most importantly I would like to thank my beautiful family, without whom this PhD would not have been possible. To my husband Neil, who supported me tirelessly through my trips to Queensland, my weekends spent at the office and nights in front of my laptop. Taking care of the children and ensuring they ‘let mummy work’ was no easy task. You were encouraging throughout always telling me to keep going and that I was nearly there. Now I finally am. To my three beautiful amazing children, Jack, Amelia and Hannah. I’m sorry for not being there for you, having to work when you wanted to play, always seeming preoccupied and forever telling you that ‘it’s nearly over’. I hope one day you will understand why Mummy took this journey and you’ll be proud, but for now it’s your time and I can’t wait to make up for every lost minute with you. I love you all to the moon and back and am so very proud of each of you. Beginning a life in academia and even contemplating embarking on a PhD journey was down to one inspirational person; Professor Carol Cox. Carol, you have always been my iii inspiration for what I want to be as an academic. Your ongoing support, encouragement and friendship has meant so much to me and even now when we are in separate continents, I still remember you fondly and continue to strive to be the academic, practitioner and researcher that you are. To my colleague, mentor and someone I now consider a friend, Dr. Christina Aggar. Thank you for your encouragement and support throughout the last two years. Every time I considered throwing in the towel, you were there with reassurances and sound advice. Thank you for listening, never judging and for all of the opportunities that you have, and continue giving me. To my principal supervisor Associate Professor Jennie Barr, thank you for ‘taking me with you’ so that I didn’t have to change supervisors again! You shared your addictive passion for research, kept me going and entertained me with your stories, enthusiasm and encouragement. Thank you for your guidance and mentorship throughout this process. Dr. Dolene Rossi you listened to me endlessly and never appeared to tire. You challenged me to be a better writer and researcher and for that I am grateful. Dr. Clare Harvey thank you for your support in the latter part of my candidature and your ‘expert eye’ on the subject matter. Finally, I would like to thank all of the rural and remote nurses that participated in this study. I am in awe of the work that you do each and every day. Thank you. iv Acknowledgement of support provided by the Australian government This RHD candidature was supported under the Commonwealth Government’s Research Training Program/Research Training Scheme. I gratefully acknowledge the financial support provided by the Australian Government. v Acknowledgement of professional services Professional editor, Rachel Robson provided copyediting and proof-reading services, according to the guidelines laid out in the University-endorsed national guidelines, ‘The editing of research theses by professional editors’. 15th April 2019 (Original signature of Candidate) Date vi Declaration of authorship and originality I, the undersigned author, declare that all of the research and discussion presented in this thesis is original work performed by the author. No content of this thesis has been submitted or considered either in whole or in part, at any tertiary institute or university for a degree or any other category of award. I also declare that any material presented in this thesis performed by another person or institute has been referenced and listed in the reference section. 15th April 2019 (Original signature of Candidate) Date vii Copyright statement This thesis may be freely copied and distributed for private use and study; however, no part of this thesis or the information contained therein may be included in or referred to in any publication without prior written permission of the author and/or any reference fully acknowledged. 15th April 2019 (Original signature of Candidate) Date viii Abbreviations A&E Accident & Emergency ABS Australian Bureau of Statistics ACT Australian Capital Territory AHP Allied Health Professional AHPRA Australian Health Practitioner Regulation Agency AHW Aboriginal Health Worker AIHW Australian Institute of Health and Welfare AIN Assistant in Nursing ALS Advanced Life Support ANMAC Australian Nursing and Midwifery Accreditation Committee ANMC Australian Nursing and Midwifery Council ANP Advanced Nursing Practice ARIA+ Accessibility/Remoteness Index of Australia ASGC-RA Australian Standard Geographical Classification – Remoteness Area ATODs Alcohol, Tobacco and Other Drugs BLS Basic Life Support CFHN Child and Family Health Nurse ix CN Clinical Nurse CNC Clinical Nurse Consultant CNE Clinical Nurse Educator CNS Clinical Nurse Specialist CPD Continuing Professional Development CRANA Council of Remote Area Nurses of Australia DoH Department of Health DON Director of Nursing DR Doctor ED Emergency Department EDoN Executive Director of Nursing EEN Endorsed Enrolled Nurse EN Enrolled Nurse ET Endotracheal FLECC First Line Emergency Care
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