We cannot staff for 'what ifs': the social organization of rural nurses' safeguarding work

MACKINNON K. Nursing Inquiry 2012; 19: 259-269 We cannot staff for 'what ifs': the social organization of rural nurses' safeguarding work Rural nurses play an important role in the provision of maternity care for Canadian women. This care is an important part of how rural nurses safeguard the patients who receive care in small rural hospitals. This study utilized institutional ethnography as an approach for describing rural nursing work and for exploring how nurses' work experiences are socially organized. Rural nurses advocated for safe healthcare environments by ensuring that skilled nurses were available for every shift, day and night, at their local hospital. Rural nurses noted that this work was particularly difficult for the provision of maternity care. This article explores two threads or cues to institutional organization that were identified in our interviews and observations; namely staffing and safety standards, and the need for flexibility in staffing in small rural hospitals. Rural nurses' concerns about ensuring that skilled nurses are available in small rural hospitals do not enter into current management discourses that focus on efficiency and cost savings or find a home within current discourses of patient safety 'competencies'.     

The lure of the bush: do rural placements influence student nurses to seek employment in rural settings?

The aim of this study was to investigate whether rural clinical placements for student nurses at a rural university in New South Wales influence their decision to join the rural and remote Registered Nurse workforce. The study utilised a convenience sample of final year Bachelor of Nursing students at a rural university campus, and consisted of two stages of data collection. Stage One employed a pre- and post-clinical placement survey design that elicited both demographic and qualitative data. Stage Two consisted of individual interviews with a sample of final year nursing students while they were on a rural clinical placement. The findings highlight the factors that influence final year students' decisions to seek employment in rural healthcare facilities. These findings will be of interest to nurse academics concerned with ensuring that undergraduate nursing curricula relate to rural nursing practice in Australia and to those involved in recruitment of new graduate RN's to rural nursing practice.     

Defining the scope of practice of enrolled nurses in medication administration in Australia: a review of the legislation

Changing workforce patterns and changes in models of care delivery have renewed interest in the role of the enrolled nurse in Australia. A number of major reviews have confirmed the enrolled nurse as an integral member of the Australian health workforce and identified that the role of enrolled nurses is expanding in many practice settings. Medication administration is increasingly being delegated to enrolled nurses raising issues related to role, scope of practice, educational preparation, competence and delegation and supervision of nursing activities. Published reports and studies have identified a range of issues related to scope of practice nurses in Australia that have prompted the development of decision-making frameworks and a range of policies and guidelines to better define practice parameters. A review of the literature and documents available from various Australian nursing regulatory bodies related to medication administration by enrolled nurses was undertaken to determine the scope of practice of enrolled nurses in medication administration in Australia. The review confirmed that there is considerable variation in practice between jurisdictions, individual health care settings and on a daily basis in clinical practice. Despite the availability of a number of policy and practice guidelines, there is limited evidence on how they are used in clinical practice and the impact of variable policies on registered and enrolled nursing practice.     

Factors that influence the recruitment and retention of graduate nurses in rural health care facilities

Rural nursing is a distinct practice and rural nurses in Australia constitute the largest group in the rural health workforce. However, the rural workforce is ageing and the turnover of nurses in rural areas is high. In addition, rural health services are experiencing recruitment and retention difficulties; very little is known about the recruitment and retention of new graduates nurses in rural health areas and the potential long-term investment they could offer to rural health services. A qualitative study explored the journey of transition for new graduate nurses employed in graduate nurse transition programs in northern New South Wales. This paper presents two major themes from the study that describe the factors that influenced the new graduate nurse to seek and accept a graduate nurse position within a rural health setting and the factors that influenced their retention. Findings indicate that previous connection with a rural area and positive experiences in a rural health care facility during undergraduate preparation were significant factors influencing the graduate nurses' decision to pursue a rural graduate nurse position. No guarantee of a permanent appointment upon completion of the graduate program, and graduates' disappointment with graduate nurse programs, were important factors influencing their retention within rural health care facilities.     

Undergraduate student nurses’ perspectives of an integrated clinical learning model in the mental health environment

Providing nursing students with appropriate clinical practice during their undergraduate programme is critical to ensuring that graduates meet the competency requirements to gain registration as a nurse. In response to the predicted nursing workforce shortage, universities have been significantly increasing the enrolment of undergraduate nurses into Bachelor of Nursing courses. This has placed a demand on the availability of clinical placements and often universities struggle to find appropriate places. In this study, a Bachelor of Nursing course incorporated an Integrated Clinical Learning Model (ICLM) for the first time during a mental health placement. The model offered students the flexibility of attending their clinical placement over a 16‐week period instead of a traditional block of 4 weeks. The aim of this study was to evaluate the student perspective of this model and whether it prepared them for the nursing workforce. Focus groups were conducted with undergraduate nursing students following their mental health clinical placement at an acute and extended care inpatient unit. Data were analysed using thematic analysis. Main themes included preparedness for practice, maintaining a work–life balance, and perceiving they were part of a team. The ICLM deepened students’ knowledge and had a positive impact on their overall clinical learning.     

Practice nursing in rural Australia

Rural Australia faces unique issues in workforce management and health care delivery. This paper provides an integrated review of the existing literature describing the work of practice nurses in rural Australia and the perceptions of consumers. Distinct differences are evident in the role of the practice nurse between rural and metropolitan practices. A key difference is that the rural practice nurse is known within the community and plays an important role in care coordination. Findings from two studies of consumer perceptions of the role of PN in rural areas suggest that the more remotely located the consumer, the greater is their perception that the nurse works under the direct supervision of the doctor. Currently, remotely located residents do not support an expanded autonomous role for the nurse. Greater research is required to develop the role of the practice nurse in rural Australia.     

Disciplinary power and its influence on the administration and supply of medications by nurses in rural areas of Australia

Hegney D. International Journal of Nursing Practice 1998; 4 : 144–150
Disciplinary power and its influence on the administration and supply of medications by nurses in rural areas of Australia
This paper reports on aspects of a larger study into rural nursing practice in Australia, 1991–94 (D. Hegney, unpublished data, 1996). Using a Foucauldian framework for analysis of the rural nursing discourses, it presents an interpretation of the statements regarding the administration and supply of medications in rural nursing practice. In particular, it focuses on the supply and administration of medications by rural nurses working in small rural health services. It explains that there are particular issues regarding telephone medication orders and the consequent verification of these orders. It suggests that rural medical practitioners use the power of legislation with regard to the administration and supply of medications to subjugate rural nursing practice. It argues that the nursing profession itself has used, through its silence on the inadequacy of the current Poison Acts and their Regulations, disciplinary power to ensure that rural nursing practice is normalised to metropolitan nursing practice. Further, the lack of educational preparation for this rural nursing role, can be seen as a pedagogical control of rural nursing practice. This paper recommends that the Statute Law regarding the administration and supply of medications be changed to reflect the reality of rural nursing practice, and that rural nurses are prepared adequately for this aspect of rural nursing practice.     

Workplace practices with mental health implications impacting on recruitment and retention of overseas nurses in the context of nursing shortages

In response to nursing workforce shortages, health agencies in Australia and elsewhere have sought to meet the demand for nursing services by recruiting nurses internationally. While there is a major focus on recruitment, little attention is given to factors that could enhance retention of overseas qualified nurses. There are a host of factors reported in the literature that impact upon retention of overseas nurses in the workforce, including: impact of re-settlement experiences in the new country; discriminatory practices in accessing employment and negative experiences in the work place. For the benefit of long term retention of overseas nurse graduates in the workforce in Australia and globally, these experiences are major issues needing urgent attention. This discussion paper reviews the literature to explore the impact of aggression and discriminatory practices in nursing as evidence for nurses leaving the profession, and discusses the mental health implications and consequences of such practices relating to overseas nurse graduates.     

POSTSCRIPT

A New Zealand Nursing Council review of undergraduate education provides an ideal opportunity to make much needed changes to the system of preparation for mental health nurses. This article critiques comprehensive nursing education through an examination of its history in New Zealand, recent mental health reports and a projected estimate of workforce needs. Historical analysis reveals a process of marginalization and invisibilization of psychiatric/mental health nursing within comprehensive programmes with a consequent reduction of skills and a weakening of the profession. The author concludes that psychiatric/mental health nursing is a distinct scope of practice which requires specialty undergraduate preparation.     

What do graduate registered nurses want from jobs in rural/remote Australian communities?

bennett p., barlow v., brown j. & jones d. (2012) Journal of Nursing Management  20, 485–490 What do graduate registered nurses want from jobs in rural/remote Australian communities? Aim To explore and describe the needs of new graduate registered nurses in a rural and remote (R&R) setting within Australia. Background Rural practice has distinctive challenges for nurses. Nurses make up the largest and most widely distributed health workforce in Australia, outnumbering doctors 8 : 1 in R&R areas. Evaluation Literature was used to evaluate the graduate registered nurses’ needs in R&R communities. Key issues Three main themes emerged: expectations, support and workloads. Themes reflected enablers and disablers of retention of nurses as they transition from student role to new graduate practice. Conclusion New graduates are aware of their limitations as new practitioners. There is an expectation that their employers will provide a supportive learning environment for them to gain the skills necessary to become proficient and valuable employees. Implications for nursing management This commentary paper identifies the need for a structured, supported new graduate programme that recognizes and meets the needs, both clinical and social, of new graduate registered nurses in the R&R context.     

Back to the future? Views of heads of schools of nursing about undergraduate specialization in mental health nursing

Preparation of nursing students for practice in mental health settings in Australia has been criticized since comprehensive education replaced preregistration specialist education. Current and projected workforce shortages have given rise to considering the reintroduction of specialization at preregistration level as a potential solution. Support of heads of schools of nursing would be essential for such an initiative to be considered. A qualitative exploratory study was undertaken involving in‐depth telephone interviews with heads of schools of nursing in Queensland. Participants generally favoured the concept of specialization in mental health nursing at undergraduate level. Data analysis revealed the following themes: meeting workforce needs, improving quality of care, employability of graduates, an attractive option for students, and what would have to go. Participants identified many benefits to mental health service delivery and consumer outcomes. How the initiative could be developed within an already overcrowded curriculum was identified as the major barrier. This level of support is encouraging if necessary changes to the educational preparation for mental health nursing practice are to be considered.     

Rural nurses. Part II, Surviving the nurse shortage

Cost containment and the nurse shortage have impacted rural hospitals and their nursing staffs. This impact did not appreciably affect burnout levels among the rural nurses, but did evidence itself in the reports of the directors of nursing and their nurses. Cost containment brought with it layoffs of colleagues in the work setting who were neighbors or relatives. This occurred while the rural areas were already filled with the unemployed and underemployed. Unfamiliar recordkeeping increased two- and three-fold, and the 23-hour admit caused unequal work flow. Downsizing, elimination of some services and reports of rural hospital closings were threatening to the nurses, who were often the sole support of their families. The rural nurse shortage was seen to be different from the national nurse shortage in significant ways. Except for the few study hospitals that were close to population centers, nurses could not be recruited from outside the geographic area. Suggestions from the Secretary's Commission on Nursing are not all appropriate for the rural hospital nurse shortage. Rural hospitals changed in the face of cost containment, and nursing personnel also worked to contain costs. However the nurses have worked within cost and salary constraints for so long that they predict loyalty to their community hospitals can be coming to an end. The nurse shortage is being approached by minor alterations in staffing and mode of care delivery. Federal support is desperately needed by the rural hospitals to permit equitable salaries, and to support financial aid to permanent residents of the rural areas for entrance into or advancement in nursing education.(ABSTRACT TRUNCATED AT 250 WORDS)     

Agency nursing in Melbourne,Australia: a telephone survey of hospital and agency managers

BACKGROUND: Agency nursing is a poorly understood and under-researched phenomenon. Despite the considerable costs and possible benefits of using agency nurses, little is known about the nature of agency nursing from different perspectives, including hospital and agency managers. AIM: To describe the professional relationship between hospitals and nursing agencies, utilization trends of agency nurses, and institutional policies relating to the employment of agency nurses. METHODS: A telephone survey was conveyed to managers of 70 acute hospitals (service purchasers) and 26 agencies (service providers) to provide baseline information on the utilization of agency nurses in acute hospitals in Melbourne, Australia. Introductory telephone calls were made to the chief nursing officers of the hospitals and the chief executive officers of nursing agencies in order to explain and seek approval for the proposed project. Approval to conduct telephone interviews was obtained from 30 acute hospitals and six agencies, representing a response rate of 43% and 23%, respectively. Separate questionnaires were used for the two categories of respondent. In some cases the questionnaire could not be completed using the telephone and a copy was then sent by post for completion. RESULTS: Findings revealed the high utilization of agency nurses in hospitals, the limited nature of continuing education for agency nurses, tensions between matching agency nurse qualifications with acute specialty needs and the notion that agencies preferred nurses to be flexible in their work assignments. CONCLUSIONS: The study was limited by the fact that the final sample was small (30 hospitals and six agencies), and therefore may not be representative of the wider population of Melbourne hospitals or agencies. However, it provided evidence on the utilization of agency nurses in public and private hospitals that will help shape policy on the regulation of the agency nursing workforce.     

Comparing nurses' intent to leave or stay: differences of practice environment perceptions

Few existing studies have compared nurses' perceptions of the practice environment in relation to intent to leave or stay in employment and nursing concurrently. This study compared the differences between Taiwanese nurses' intent to leave or stay in employment and nursing, as related to their perceptions of the practice environment. A cross-sectional questionnaire survey was conducted at four hospitals in southern Taiwan. Questionnaires including the Chinese Nursing Practice Environment Scale, regarding intention in employment and nursing, were distributed to 535 nurses who provided direct patient care in Taiwan hospitals. Taiwanese nurses with intent to stay perceived the practice environment as better than nurses with intent to leave employment and nursing. The influences of the nursing practice environment on nurses' intent in employment and nursing were supported preliminarily. Targeting interventions to enhance participation in hospital affairs and adequacy of staffing and resources could be beneficial for a stable nursing workforce.     

A review of evidence for the practice learning environment: enhancing the context for nursing and midwifery care in Scotland

This paper considers the issues which will ensure practice learning excellence in the future and in particular how these will impact on the delivery of high quality nursing and midwifery care in Scotland in the United Kingdom (UK). This will include the inter-dependency of learning in practice for undergraduate pre-registration students and qualified practitioners, in particular continuing professional development as a lifelong experience and its link to quality care provision. We contend that the practice learning environment is the whole of an organisation which values and supports the development of its workforce through education. Partnership working between education and service providers is central to ensuring an educated and professionally prepared workforce. Both nursing and midwifery are practice-based professions which are accountable for, and charged with assuring, effective public health and safety. The initial paper which established the key issues discussed here was initially written as one of the key background papers for a consensus conference to inform NHS Education for Scotland’s nursing and midwifery workforce development over the next five years (NES 2009).     

The demographic profile of alcohol and other drug (AOD) nurses in Australia: Experienced,highly qualified… and endangered?

BackgroundLittle is known about the demographic profile of Australian alcohol and other drug nurses, a key part of the workforce that provides care to healthcare consumers who seek treatment for problematic alcohol and other drug use.AimTo explore the demographics of the alcohol and other drug nursing workforce in Australia.MethodElectronic survey, comprising quantitative demographic questions and qualitative responses. Statistical analysis was conducted to explore workforce demographics, and thematic analysis used to explore free-text responses.FindingsIn total, we surveyed 337 nurses working in alcohol and other drug nursing positions. Most (81.3%) were female, and postgraduate qualified (67%). Approximately 60% of participants were aged 45 and over, and 9% 31 or under. Participants were highly experienced in the specialty (mean 13.72 years, SD 10.10), and in nursing overall (mean 26.29 years, SD 13.38). When compared with the total nursing workforce, alcohol and other drug nurses are older, with proportionally fewer nurses under the age of 35. Qualitative themes indicate workforce sustainability and attracting new entrants as key issues.DiscussionThese findings indicate that the Australian alcohol and other drug nursing workforce is older, with many participants nearing retirement. There are fewer younger entrants to the specialty, lending support to the argument that alcohol and other drug nurses are endangered.ConclusionThere is an urgent need to develop strategies to encourage nurses to take up alcohol and other drug nursing; especially considering the number of highly experienced and qualified nurses likely to leave the specialty soon.     

The dual roles of rural midwives: the potential for role conflict and impact on retention

Nurses and midwives continue to make up the largest proportion of the health workforce. As a result, shortages of nurses and midwives have a significant impact on the delivery of effective health care. Shortages of nurses and midwives are known to be more pronounced in rural and remote areas where recruitment and retention remain problematic. However, rural nurses are often required to be multi-skilled, which has led to expectations that nurses who are also midwives, are required to work across areas of the hospital to help to address shortages. For midwives this issue is even more problematic as they may actually end up spending a very small percentage of their working day involved in the delivery of maternity care. This workforce strategy has the potential to seriously erode the skills of the midwives. Situations such as this are implicated in attrition of midwives because of the role stress that results when they are required to work in models of care where they experience the constant pull to work between departments and across roles. This paper addresses the requirement for midwives in some rural facilities to work across roles of general nurse and midwife and outlines the issues that arise as a result. In particular, the paper links the concepts of Role Theory to the requirement for midwives to work in dual roles and the potential for role stress to develop.