Rural community nurses: Insights into health workforce and health service needs in Tasmania

There have been significant changes in the community nursing role and function since its establishment in the 1850s, with particularly marked changes over the last decade (Boran, 2009). Healthcare is one of the highest spending public sectors of most westernised economies and has undergone greater budgetary restraints recently. These measures have included bed closures, job losses, longer waiting lists and ever increasing costs to access health services, which may contribute to deteriorating health outcomes in the future (Humphreys, 2009). Health remains the object of governments who aim to downsize and cost shift (Oberlander, 2011). It is within this context of the current health climate that this study was conducted. Specifically, the current Tasmanian government is placed in a situation where the current $1.3 billion health budget needs to find $100 million worth of savings in 2011 -2012, increasing to $150 million by 2014-15 (Giddings, 2011a). It is anticipated this could be achieved through a number of measures which include reducing the duplication in areas such as payroll; reducing expenditure on locums; reforming procurement; and reducing the number of employees up to 2300 full-time equivalent jobs – including frontline services (Brown, 2011; Giddings, 2011a, 2011b; Poskitt, 2011). In addition, a reduction of elective surgery and other services has occurred over this time leading to increased waiting times and delays in diagnosis (Glumac, 2011; Poskitt, 2011). These changes in medical and surgical care suggest there may be a need to increase the provision of acute health care in community settings, while the implementation of illness prevention and health promotion programs is seen as an urgent priority. It is believed that community nurses are well situated within the community to meet these growing health care needs and implement such programs. In addition factors such as the recent changes in the demographic structure of Tasmania’s population and to health policy and management structures further augment the role of community nurses and have altered service delivery expectations. Previous research has outlined that these and many other factors have placed significant additional workload pressures on community nurses which, when combined with working in rural areas, have the potential to create significant dissatisfaction within the role. In the future this could potentially impact the ability to recruit and retain community nurses in rural areas where they often work in isolation. At times they may feel overwhelmed, stressed and undervalued while undertaking diverse responsibilities in their rural practice. Anecdotally Tasmanian community nurses have indicated this is the case; however there is very limited research to more accurately identify and quantify the issues which impact their practice in rural Tasmania (Terry, 2012). This research project aimed to identify the personal and organisational challenges encountered by community nurses working in rural areas in the North and North-West of Tasmania. It also sought to examine and understand the skills, practices and experiences of community nurses when caring for clients in rural community settings where other health care organisations are limited or not always present. The research adopted a qualitative approach using semi-structured interviews for data collection. Fifteen community nurses were interviewed in total, two from the private sector and thirteen from the public sector. With the exception of the private sector nurses, all worked exclusively in rural or remote areas. Eleven community nurses were from the North of the state, while four were from the North-West. Data collected from participants provided information in relation to the motivation for working as a community nurse; the skills and experience as community nurses; the benefits and challenges of working in a community nursing role; changes in the expectations of the role; and the future development of the role. Nurses interviewed also provided information on the organisational and personal factors impacting on the provision of community nursing services. There were a number of variations in the structure of the community nursing service delivery across the North and North-West. Community nursing services ranged from twenty-four hour seven day a week, to Monday to Friday with some after hours and weekend services, while others were day services with no weekend or public holiday cover. The services again ranged from being predominantly centre-based to mostly community based. Others utilised a team approach, while some services were run by a sole practitioner. The types of service provided were broad with the most common services related to the provision of wound care, palliative care and continence assistance and support. In some areas community nurses were required to provide emergency care and support, while others provided more acute care, such as the administration of antibiotic therapy, de-accessing chemotherapy, Baxter pump therapy, and PICC line management. Alternatively, private sector community nurses were involved in and focussed on the assessment and review of clients. There was evidence that community nurses had ‘picked up’ aspects of health care when no other services or staff members were available to meet the needs of the community. For example, the provision of foot care or the provision of GP practice nurse services in more isolated areas. Despite the variations and diversity observed across the rural community nursing services, the nurses discussed high levels of job satisfaction and long-term employment, regardless of any issues or challenges they were encountering. The key motivations for working as a community nurse included:  The primary health approach and philosophy of care which was valued, and the ability for flexibility in meeting client needs;  Client autonomy, service appreciation and greater client focus within the service; and  Practicalities of employment, such as not having to work shifts, “family friendly” hours and their employment being located near to where they lived. Within the study, it was shown that the most common change being experienced at the time of the study was related to role expectations. There was an expectation to provide increased chronic disease management, and a greater focus on health promotion services while moving the service away from undertaking tasks considered ‘non-nursing’ such as bathing, showering and monitoring services. Key challenges identified included:  Coping with altered and increasing expectations of the role and maintaining the knowledge and skills to deal with the diversity of the role;  Communication and integration with other service providers particularly relating to discharge planning, integration of care and having open dialogue with acute care settings;  A lack of understanding regarding the role of community nurses and being undervalued;  Meeting increased workload requirements, role expectations and non-nursing administrative requirements;  Maintaining boundaries within the rural community nurses were living and working in;  The emotional stress and pressure of working with palliative care clients;  Workplace Health and Safety issues associated with working in isolation; and  Access to training, support, and annual leave due to lack of relief staff. While a number of key challenges have been identified, nurses felt they were well supported by their managers and well-resourced from a practical perspective to undertake their role. In addition, it was evident the more experienced Community nurses had developed specific strategies or approaches to address these challenges. For example, programs of rotation through Community nursing service areas were established, while volunteer programs and additional cancer support programs were developed to provide additional support to clients. This was indicative of the nurses using and developing innovation, initiative and self-reliance within the service. This report provides insight into what was found in the Tasmanian context and then discusses it in the framework of the international literature concerning the health workforce and health service needs of Community nursing. As a result, a number of key recommendations were formulated to address a number of key concerns highlighted. However, it must be noted that due to the small sample size and the diversity in roles and service delivery types it is difficult to make broad generalisations for services outside Tasmania. Nevertheless, five key recommendations are made to enhance and augment the role of community nurses and the service they provide in Tasmania.