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Easing the strain

Understanding why nurses don’t stay in the bush is integral in improving the rural workforce, writes Sue Lenthall.

Working in isolation, a lack of permanent staff and cultural issues all contribute to the high levels of psychological distress, trauma and emotional exhaustion experienced by Remote Area Nurses.

These stressors, plus a number of others, were identified in a recent research project, ‘Back from the Edge, Reducing Stress Among Remote Area Nurses (RANs)’, led by the Centre for Remote Health in partnership with other universities, health service partners and professional groups.

However, while remote area nursing is stressful, it is also rewarding. The research found that RANs also enjoy high levels of work engagement and moderate levels of job satisfaction.

While the research gathered a great deal of data about levels and types of stressors it also aimed to develop, implement and evaluate actions at a system level that reduce and prevent occupational stress - all vital in improving recruitment and retention in remote areas.

Workgroups of RANs and health service managers working in remote indigenous communities in central Australia and in the Top End of the Northern Territory discussed the results from the national survey, and then developed action plans aimed at organisational rather than individual changes.

The action plans were further work shopped with implementation committees of middle managers in central Australia and in the NT Top End. Some actions were implemented at this level; others were referred to the high level reference group which contained senior managers for consideration and implementation. Three cycles of this action research were conducted over a 12 month period.

One of the main priorities of the work groups was the education of RANs. Nurses perceived that the education of RANs was still far from sufficient. The number of vacancies and the increase in agency and short term staff in recent years is causing increased stress among permanent staff.

In particular participants reported significant orientation burnout, where in a small team they were required to orientate new staff continuously. Participants also reported feeling anxious about the skills and knowledge of many short term and agency staff as they often came to the communities without any orientation.

Actions that were developed included the strengthening of the NT education pathways program for RANs and establishing a steering group to support that initiative. A career structure for RANs was also introduced that enables less experienced registered nurses to be employed at a lower level and supported to develop their skills.

The NT Department of Health and Families has a very good orientation program for RANs which all permanent staff are required to undertake. They are also allowing some agency staff to participate.

However, the orientation of short term and agency staff is still an issue.

Further actions included the establishment of education requirements for managers and linking these to career pathways. Other actions concerning the education of RANs included increased on-site education of RANs and improved education on vicarious trauma and post traumatic stress disorder (PTSD).

Another identified priority was the need to increase permanent relief staff to enable RANs to take leave and attend professional development program. Recommendations were made to the health authority to increase the current casual pool and establish permanent reliever positions.

To reduce the workload of RANs it was decided to reduce single nurse clinics by employing additional staff. These were reduced in Central Australia from six to two. Measures were introduced to reduce workload from visiting teams and to increase employment and training of ancillary staff including administration, cleaners and drivers.

Safety while on-call was a significant issue. It was agreed that all clinics would get a telephone, intercom system and the use of drivers for night time call outs would be investigated. Managing aggression and risk management would be reintroduced as part of RAN orientation and risk assessment procedures would be reviewed.

Actions were also developed to improve infrastructure and equipment. An equipment manager position was introduced. Participants also discussed numerous strategies to increase accommodation, a major limiting factor to increasing staff, improve cleanliness of clinics and accommodation and improve the maintenance and repairs to clinic and staff accommodation and ensure that every community had at least two vehicles. However effecting systemic change in these areas proved difficult.

RANs are the backbone of remote area health service delivery to the neediest populations in Australia. High levels of occupational stress among RANs contribute to turnover of staff and quality of health service delivery. By employing a bottom-up action research approach, RANS were empowered to contribute to system changes to decrease occupational stress.

Stress among RAN’s
The main stressors identified in the Centre for Remote Health’s research project include:

Responsibilities and expectations. There is a feeling among RANs that the community and health services have unrealistic expectations and that they, themselves, cannot meet the demands arising from both the community and the health service. This is often exacerbated by the advanced practice role that RANs are required to perform without adequate professional preparation.

Emotional demands. Any job that entails working with people has emotional demands. The poor health of Indigenous peoples, the frequency of emergencies, and the regularity of a pre-existing relationship or association between the RAN and client can add weight to the emotional demands of RANs.

Workload. The sheer volume of work is a major issue for RANs, with long working days and higher morbidity rates in many communities. The ‘frontline’ nature of remote area health work and the lack of medical and allied health presence dictate that nurses are subject to greater workloads, including frequent on-call responsibilities.

The remote context and isolation. Working in isolation is the most pervasive feature of remote area life. Isolation extends beyond geography to encompass social and professional life. In particular, the social support provided by family and friends is less accessible.

Cross cultural issues and culture shock. Most RANs work in remote Indigenous communities and face a range of challenges relating to cross-cultural environments. These include differences in language, social norms and gender roles, disparity in religious and spiritual practices, and contested values and beliefs relating to health and illness.

Staffing issues. Recruitment of adequate staff is often difficult in remote areas. Many remote clinics have vacancies or have positions that are temporarily filled with short term agency staff. This situation decreases the capacity of health services to provide staff with time off for in-servicing or annual leave. The increase in short term temporary staff (who have often been poorly orientated) adds to an existing burden for many RANs.

Poor management practice in remote health, including lack of management support, was a major issue among RANs. These poor practices are compounded by the distance most managers are from the RAN workplace and the limited number of health clinic visits.

Difficulties with equipment and infrastructure. Vast distances also impact on the difficulties experienced with equipment and infrastructure. There is generally inadequate housing for RANs which is further compounded by the cost of building in remote areas and the often poor building that happens. To get a piece of equipment repaired is often difficult and time consuming. Issues with equipment and infrastructure cause a great deal of frustration for RANs.

Workplace violence. Concern for personal safety and the witnessing and experience of workplace violence was also highlighted as a significant issue.

Sue Lenthall is project manager of the Centre for Remote Health’s Stress Project.

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