Scope of Nursing Practice in Australian Rural and Remote Nursing - Essay Example

SCOPE OF NURSING PRACTICE IN AUSTRALIAN RURAL AND REMOTE NURSING Scope of Nursing Practice in Australian Rural and Remote Nursing Introduction The scope of the nursing practice is very extensive for the most part. It covers independent nursing care to assistance rendered to other health professionals in the care of the patient. The nursing practice is based on standards of the medical practice which fit the different qualities and trainings within the profession. In the Australian rural and remote setting, the implementation of the appropriate standards of nursing care and practice may be on a wider scale and on a different level of implementation. This paper shall discuss the scope of nursing practice in the Australian rural and remote setting. This paper is being carried out in order to establish a thorough and clear understanding of the subject matter. Discussion The main goal of government and legislative agencies, including the QNC, RCNA, and the NSW Nursing Registration Boards is to ensure that the public receives safe and adequate nursing and health services. Jacobs, (2007, p. 14) emphasizes that “differences in class, gender, personal experiences, values and beliefs have caused gulfs within nursing throughout its history, and no less than in the political, educational and regulatory development of advanced practice”. In the global setting disparities in the delivery of nursing care has been evident between countries, and even between territories within countries themselves. This is also apparent in Australia where the rural and the urban settings have different applications of nursing practice. Most countries have considered different legal standards and it has been declared that no one size fits all. Nevertheless, healthcare delivery is the responsibility of all states and territories, and majority of such responsibility falls on the federal governments. In effect, most states can be manipulated by the amount of money released by the federal government (Gardner, 2005, p. 382). To promote the standards of the practice and ensure the safety and quality of the services, many governments have set forth laws and different systems of clinical governance. In 2008, new guidelines for advancing nursing practice and reviewing competence was announced by the Queensland Nursing and Midwifery Council. The nursing and midwifery practice is all about the “application of knowledge, skills and attitudes towards alleviating, supporting or enhancing actual or potential responses of individuals or groups to health issues” (Queensland Nursing Council, 2010, p. 9). Their practice also includes administration of direct care, as well as assessing, planning, implementing and evaluating care and coordinating care; it also includes leading, managing, teaching, education, health promotion and undertaking research as well as developing nursing and midwifery policies. Nurses and midwives are called on to follow standards under laws and common law traditions relevant to the nursing practice. These standards include the national code of ethics which contain the moral standards of care; the national code of professional conduct; the Australian Nursing and Midwifery Council national core competency standards which set forth the scope of practice for nurses and midwives beginning their practice; and other Queensland Nursing Council endorsed codes and standards (Queensland Nursing Council, 2010, p. 10). These standards also apply to all territories and areas of Queensland, including Brisbane. These standards are very much in accordance with the standards of the practice as set forth by the international community; they are meant to apply to all areas of Queensland, from the urban to the rural areas. This scope of practice will likely expand through the years due to the shortage being experienced in the health care practice, especially in the rural and underserved areas. In fact, many nurses in these underserved areas are already performing responsibilities which are beyond their scope of practice and which are often double their expected services rendered. Advancements in medical practice have also made it difficult for different professions to be the only experts in medical care. Consequently, there is often an overlap of roles between physicians and ANPs in terms of who provides the best care for patients. The professional scope of practice comes from the different practice specialties, as well as national government groups which provide broad definitions for the specialty roles, the population served and the practice setting. These all play a crucial role in managing the individual coverage of practice (Verklan, 2008). ANPs in Australia are affected by different laws and regulations, in addition to the provisions of the Nursing Act of 1992. This act relates to the scope of practice, educational preparation, and clinical qualifications. In some cases, amendments to laws have been implemented in order to ensure that the nurses do not practice outside their legal scope of practice. There are four areas of accountability in the nursing practice. Wiseman (2007, p. 167) discusses this to be: accountability to the patient, accountability to the public, accountability to the employer and to the profession. The law in relation to advanced nursing practice is based on the Bolam test which declares that a clinical professional would have carried out his duty if what he has done would be supported by a responsible group of practitioners in the corresponding specialty at the time (Bolam v. Friern Barnett Hospital Management Committee, 1957). It may sometimes appear that inexperience would reduce liability for a practitioner however, beginners are within the standard of competence (Wiseman 2007, p. 173). In effect, nurses in the advanced practice have to perform based on the levels of doctors and other health providers who perform the role from the very beginning. Furthermore, it is therefore important for research to be examined and used in order to evaluate whether or not nurses and doctors can administer appropriate care for patients (Chiarella, 2006, p. 649). The rural and remote areas of Australia are subjected to more vulnerable states, more than any other population. Their situation shall be presented below. Australia’s rural and remote populations These populations have poorer health as compared to their urban counterparts, especially in relation to health outcomes. They have higher mortality and lower life expectancy rates (Strong, 1998, p. vi). They also usually have higher hospitalization rates for some causes of ill health. More statistical reports indicate that rural females expect to live about 80.8 years, about 0.4 years less than those living in the capital cities; males in the rural areas are expected to live for 74.7 years, as compared to those living in capital cities who live 75.6 years. The males in other remote areas live to about 71.5 years, 4 years less than those living in cities; and females in other remote areas live up to 77.4 years, 4 years less than those in capital cities (Strong, 1998, p. vii). In terms of fertility rates, women in rural and remote areas usually have more children than those in the cities. Further studies also indicated that total male and female death rates were 6% lower for those in the capital cities, with injury being a main cause of premature mortality in the remote areas, especially for males. In fact, death rates for males caused by injuries in other remote areas are double those of males living in capital cities (Strong, 1998, p. viii). Hospitalizations for injuries were higher in the rural and remote areas; falls among the elderly were also higher among the rural and remote area dwellers. CHD were also higher in the rural and remote areas and mortality rates for this disease was also higher in the rural and remote areas (Strong, 1998, p. viii). Health risk factors, like alcoholism were higher in rural and remote areas; smoking was also more prevalent in these areas. Those in the rural and remote areas do not have as much access to healthcare, as compared to their city counterparts. They had a lower supply of GPs and pharmacists; nurses delivered higher proportion of care in the rural areas as compared to those in the cities. There were less medical specialists and less hostel accommodations for the aged members of society in the rural areas. Medicare data also indicates that those living in the rural areas availed of the health services to a lesser degree than those living in the metropolitan area (Strong, 1998, p. viii). Many of those living in the rural and remote areas are the indigenous peoples and their medical condition is much poorer than any other population in Australia. They have high poverty rates, high rates of CHD, alcohol-dependence, drug dependence, smoking, have high mortality rates, have shorter life-spans, have high maternal and infant mortality rates, and are prone to various communicable illnesses, and chronic care diseases like diabetes, hypertension, and heart related illnesses. Scope of nursing practice in the rural and remote setting As was previously mentioned, nurses play a bigger role in the rural and remote areas – more than the role that the nurses in the capital cities play. In the community or hospital setting, nurses are expected to have the clinical and academic competencies which fit the higher level of autonomy and the necessary skills in certain environments; these nurses must work with each other as a team; they must be guided by clear and appropriately developed standards for clinical decision-making and delegation in relation to laws; they must be committed to mutual respect and coordinated models of care which are at the very core of nursing practice. In a paper by Sharkey, et.al., (2003, p. 750) the author discussed that there are two kinds of nurses who work in the rural areas of Australia, and these are the rural nurses and the remote area nurses. These nurses have more or less functions which considered independent nursing interventions and determined from the needs of the communities where the nurses practice. The roles of nurses in rural communities are different from the nurses in the urban communities; these roles are also impacted by different factors, including geographical location, population density, type of employment agency, and health needs of the community. Experts argue that the contemporary rural and remote nursing functions are similar to that of the advanced nursing practice; in effect, rural nurses possess skills and knowledge beyond what is taught to them in basic nursing education. Wilson, et.al., (2002, p. 641) set forth how the National Health Service efforts in the UK have placed nurses in the centre of primary care services and in line with the general practitioners playing a supportive function for nurses. In the year 2002, there were about 40 walk-in facilities in England, featuring early access to nursing services in primary care (Rosen, 2002, p. 241). Other efforts in providing nursing care included NHS Direct, NHS walk-in facilities, and nursing personal medical plans. These efforts serve to place nurses in positions of first point of contact with clients seeking primary care. Studies carried out in the US and the UK show that nurse practitioners have outcomes similar to general practitioners and even report better patient satisfaction (Kennersley, 2000, p. 1043). In a study by Horrocks, et.al., (2002, p. 818), the authors sought to consider whether or not nurse practitioners provide first point of contact interventions equal to GPs in primary care. Their study covered about 11 trials and the authors concluded that nurse practitioners in the rural setting provide care which eventually leads to improved patient satisfaction, competently compared with care administered by doctors. The authors also concluded that nurse practitioners in the rural and remote setting can administer interventions which in relation to quality of care are at least as good as or sometimes even better than the care administered by general practitioners (Horrocks, et.al., 2002, p. 818). Wilson, et.al., (2002, p. 641) also points out that the adequately trained nurses can perform functions, which are usually performed by GPs, at lesser cost but at a maintained quality of service. In the US, the nurse-led mobile health clinics circulating in rural areas have manifested improved provision of preventive health remedies and reduced utilization of emergency services. The WHO Strategic Directions for Strengthening Nursing and Midwifery Services document shows clear support for the view that as nurses are given free rein to apply their skills, they can potentially provide a high quality of services at more or less reduced costs (WHO, 2002). The current primary care functions have not yet fully considered the issues of social exclusion and multiple deficiencies. Families undergoing various issues, including unemployment, relationships problems, inadequate education qualifications, and poor health outcomes often find themselves being passed on from agency to agency (Sharkey, et.al., 2003, p. 751). This disjointed approach to health services causes various families to be deprived of adequate intervention programs. The WHO Advisory Group of Nursing and Midwifery pointed out that in different parts of the world, nurses are the best and the largest group of workers which are in the most appropriate position of providing rural health care (WHO, 2001). The advisory group also pointed out that due to the expanded role of nurses, they are also initiating new activities towards the management of priority areas providing services to vulnerable groups. In considering the previous discussion, it is suggested that the rural and regional areas in Australia consider other models which will involve root and branch restructuring in primary care services. This restructuring would likely see the family nurse practitioners and the GPs as the point of first contact for the rural and remote communities; moreover, the family nurses are likely to be the primary source of care for rural areas. Family health nursing is already attaining momentum in the European region as the main structure for the nursing practice; it is also considered the main strategy for the WHO (Sharkey, et.al., 2003, p. 751). The family health nursing is a WHO strategy in order to improve the access of the people to community-based services; this type of service is however not yet available in Australia. This type of service would work well for Australia because, it would provide for practice undertaken within an entire range of social services and networks; it is through the social community’s roles and functions that these nurses come forth as the group which is most competent to handle health inequalities and disparities. The contemporary rural health models may be gaining the opposite effect because there seems to be proof that the health of the indigenous community may not be improving in relation to other Australians (Ring, 1998, p. 528). The family health nurses are expected to coordinate health services, social services, housing, community building activities, and education services for the vulnerable members of the community. Family nurse practitioners are now a crucial addition to rural and remote nursing because they are considered expert clinicians who manifest leadership as consultants, educators, and researchers (Sharkey, et.al., 2003, p. 751). Such practitioners would then assess and manage the medical and nursing issues and are considered to be well-established personnel in the US and Canada. Their practice considers health promotion and maintenance, disease prevention, and diagnosis, as well as management of acute and chronic diseases which also include history-taking, carrying out physical exams, ordering, performing, and assessing diagnostic and laboratory exams and prescription of pharmacological agents and the interventions which manage the diseases diagnosed (USDHHS, 2002). With the probability that primary care nurses can carry out many, sometimes, all functions of the GP and carry these out in cost-effective way, it is therefore important to consider a policy of role interchangeability. In this case, what is significant is that the person performing a certain function can carry out his practice competently, rather than focusing on which professional should have performed the role. Rural and remote nurses considered as independent nurse practitioners often carry out Pap smears on their women patients. These practitioners also cover general women’s health. In relation to women’s health, they are also obliged to provide lessons in family planning and family health (Offredy, 2000, p. 276). Their caseload often covers a wide rural area while being contracted to work with different agencies and organizations, including community health centres, neighbourhood houses, hospitals, and general practitioner clinics. These nurses often provide their own equipment during their clinical placements; they are mostly self-sufficient, except for water and power (Offredy, 2000, p. 277). Thirty minute appointments are often granted to patients at which time, the patients receive information in relation to the role of nurse practitioners, procedures in the smear tests, and equipment to be used. Breast awareness exams are also instructed and carried out with patients. Vaginal examinations are also undertaken when deemed necessary by the practitioner (Offredy, 2000, p. 277). These practitioners often consult with patients in relation to other health concerns, extending their roles in primary care, including welfare and counselling. In most of these cases, they sometimes do not receive compensation. The pathology forms for the Pap smears are also completed by these nurses and the sample of cervical cells sent to the cytology laboratories (Offredy, 2000, p. 277). Decisions are then made by the practitioners in relation to further referral to GPs. Follow-up appointments are also subsequently carried out with the nurses. Community health practitioners are also nurses in the rural and remote setting. They are often nurses working as such because of the closure of a local community hospital (Offredy, 2000, p. 278). In effect, the roles of these nurses have shifted from that of a traditional hospital nurse to a primary health care nursing practitioner role. These nurses are often ill-equipped to carry out the roles of rural and remote nurses. Nevertheless, they have to make the appropriate adjustments to ensure that the community would still have access to primary health care. In the rural and remote setting, there are usually midwives, working alongside nurses in relation to women’s health and maternal and child care (Offredy, 2000, p. 278). In instances when medications are needed by the patient, the community health nurse is obliged to contact the GP and relay her findings and suggestions. Telephone orders for medication are then transmitted from the GP to the pharmacist and then given to the patient (Offredy, 2000, p. 278). Considering these functions, a community health nurse does not have as much independence in her practice in the rural setting as compared to the independent nursing practitioner. The independent nursing practitioner is trained to function with autonomy, whereas the community health nurse has been thrust into the role of rural and remote nursing because of necessity. But, for the most part, their actions serve the community’s needs, only with one nurse functioning at a lesser degree than the other. The community nurse practitioner is also a nurse working in the rural and remote setting. They are tasked to assist young mothers under 25 years of age by organizing a support group for them; to establish women’s health programmes; gay and lesbian support groups for young individuals; and to coordinate tutoring classes for children 11 to 17 years of age (Offredy, 2000, p. 279). They often work in areas with no medical practitioners permanently in the area. Their work involves offering advice on the use of contraceptive pills, self care, pre-test counselling for HIV or sexually transmitted diseases, and pre to post-pregnancy termination counselling (Offredy, 2000, p. 279). These services are primary services which nurses need to consider for the community. They can competently be provided by the nurse based on her training and her expertise; and can be followed up through referrals with the available GPs. Conclusion Rural and remote nursing revolves around the provision of primary health care services. These nursing services cover a range of services from maternal to child care, as well as counselling and the establishment of support groups. In effect, the scope of nursing practice for the rural and remote nursing covers more than the minimum legally mandated roles and functions of a nurse, it also covers general health services in the absence of a fully functioning hospital and in the absence of a GP in full attendance. In other words, the beginning and end of care is the nurse practitioner. In instances when the nurse assesses the patient to be in need of further care, her work also expands to accommodate the referral process to the general practitioners and to higher healthcare institutions. To a wider extent, the nurse in the rural and remote setting has a wider area of responsibility and more responsibilities as a nurse to go along with it. Works Cited Chiarella, M. (2006), Advanced nursing practice, The Journal of Advanced Nursing, vol. 24, pp. 649-51. Gardner, G, Chang, A & Duffield, C. (2007), Making nursing work: breaking through the role confusion of advanced practice nursing, Journal of Advanced Nursing, vol. 57, no. 4, pp. 382-91. Horrocks S, Anderson E, Salisbury C. (2002), Systematic review of whether nurse practitioners working in primary care can provide equivalent care to doctors, BMJ, vol. 324: pp. 818–823. Jacobs, S. 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