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Providing care to the isolated

The gap between undergraduate education and the advanced role of health professionals in remote areas has long been recognised by remote practitioners, writes Robyn Aitkin.

Remote Australia makes up over three quarters of the Australian landmass. The population living in remote Australia includes generational station and farming families, transient mine workers, short and long term professional people, industry employed people and seasonal tourism workers, and indigenous Australians.

With the latter group representing 48 per cent of the total population in very remote areas, and 16 per cent of the total population in remote areas (ABS, 2008), remote health practice is overwhelmingly focussed on closing the gap between Indigenous and non-indigenous health.

Looking more closely, Aboriginal and Torres Strait Islander people living in remote Australia represent one quarter of the whole Australian Indigenous population, with 79 per cent of indigenous people from the Northern Territory living in remote and very remote areas combined. Of this population, 81 per cent live in the 1187 discrete remote Indigenous communities, which house some 92,960 people (ABS, 2007).

While rural and remote people have poorer health status than other Australians, the health of Indigenous Australians is rated as the worst in the world on some indicators, in particular diabetes and renal disease. The Australian Bureau of Statistics, Australian Institute of Health and Welfare 2008 report reveals that in 2004–05, Indigenous adults were twice as likely as non-indigenous adults to report their health as fair/poor (29 per cent compared with 15 per cent).

Circulatory diseases (including heart disease), diabetes, respiratory diseases, musculoskeletal conditions, kidney disease and eye and ear problems were the chronic diseases responsible for much of the health problems experienced by Indigenous people. In addition, high to very high levels of psychological stress were reported twice as many times by Indigenous adults than non-Indigenous adults.

The hospitalisation rate for indigenous people was 14 times more often than non-Indigenous people, with an admission rate of five times greater than non-indigenous Australians for potentially preventable conditions.

Add to this overall picture poor housing, overcrowding, poverty and unemployment, lower levels of education, lower levels of health service provision and difficulties accessing health services, it is no surprise that the greatest burden of inequity between indigenous and non-indigenous Australians is found in discrete remote indigenous communities.

The provision of remote health services to these remote communities involves providing health care to small, culturally dynamic, highly mobile and dispersed populations while living in climatic conditions which are often extreme and facing problematic transport and communication with the external world.

The characteristics of the environment and this population mean that provision of health care ideally takes place within a Population Health, Primary Care framework. Therefore, remote health service provision is also strongly multidisciplinary in nature. At the same time, there are many sole practitioners within the remote health service context. This means that medical, nursing and allied health professionals employed in remote settings, by necessity, engage in an extended scope of practice compared to their metropolitan and rural counterparts. By necessity, they also need to be familiar with rapidly changing technology to overcome the barriers of geographical, professional and social isolation.

By far the largest health workforce represented in remote indigenous communities are nurses.

Whilst RANs provide health care to people in other contexts, 43 per cent of registered nurses working in remote or very remote settings work in discrete indigenous. Recruitment of health professionals to remote area services and retention of quality health practitioners within remote area health is a significant problem.

The gap between undergraduate education and the advanced and extended role of health professionals in remote areas has long been recognised by remote practitioners.

The numerous commissions and reports into Indigenous health including the National Aboriginal Health Strategy (1989), the Royal Commission into Aboriginal Deaths in Custody (1991), and the National strategies for improving Indigenous health and health care (2004) have highlighted the educational needs of doctors, nurses and other health professionals in areas where Aboriginal and Torres Strait Islander people are concentrated.

In particular these reports emphasised the need for education in the areas of cultural awareness, primary health care and the health conditions of indigenous people (NAHS Working Party, 1996). In addition, despite the unique context of remote health, a health professional working in a remote indigenous community requires no more than current registration and an interest in the area.

In November 1997 a national forum including several professional bodies, educational institutions, consumer groups and the various disciplines was convened to identify the educational needs of the emerging discipline of remote health practice.

This forum outlined a curriculum that was underpinned by the desire to develop graduates with the following knowledge and skills:
* An understanding of remote health history, cultural and social principles
* An understanding of clear models of remote area practice
* The ability to deliver high quality primary health care
* A commitment to community development
* A capacity for teamwork and management skills
* The capacity to cope in isolated and cross cultural situations, and
* The ability to practice in culturally safe manner.

In 1998, the Council of Remote Area Nurses (CRANA, now CRANAplus) partnered with Flinders University to address this curriculum content. Together CRANA and Flinders offered an articulated Master of Remote Health Practice, with entry and exit points at Graduate Certificate and Graduate Diploma.

The program has been facilitated through the Centre for Remote Health, a University Department of Rural Health, and joint centre of Charles Darwin University and Flinders University. Ten years on, the suite of courses has been evaluated, and in 2011, offerings have been expanded to include the Master of Remote and Indigenous Health and the Master of Remote Health Practice: Nurse Practitioner.

The Master of Remote Health Practice: Nurse Practitioner is accredited with the Nursing and Midwifery Board of the Northern Territory and the first group of Remote Nurse Practitioner candidates completed the program in 2010.

This is a world first and major milestone in the contribution to improving remote health outcomes and preparing the professionals who provide services in remote Australia. This program has been carefully designed for the remote, indigenous Primary Health Care context in collaboration with CRANAplus, and is delivered by leading academics and professionals in remote health and nurse practitioner practice.

Further information about the Remote Health Practice: Nurse Practitioner course at www.flinders.edu.au/courses/rules/postgrad/mrhp-np.cfm and the Remote and Indigenous Health course at www.flinders.edu.au/courses/rules/postgrad/mrih.cfm n

Robyn Aitkin is senior Research Fellow and head of education at the Centre for Remote Health.

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