factors effecting engagement or disengagement for rural nurses · literature review report factors...

December2016

FACTORS EFFECTING ENGAGEMENT OR DISENGAGEMENT FOR RURAL NURSES

LiteratureReviewReportFactorsEffectingEngagementandDisengagementforRuralNursesCRANAplusProfessionalServicesDecember2016 Page2

AcknowledgementThisLiteraturereviewwasundertakenbyMaryGraceBinghamThe moral and intellectual rights associated with anything developed or written while in theemploymentofCRANAplusresideswithCRANAplus.RecommendcitationoCRANAplus,Factorseffectingengagementordisengagementforruralnurses:aLiteraturereview.CRANAplus,2016,Adelaide


TABLEOFCONTENTS

EXECUTIVESUMMARY...................................................................................................................5

INTRODUCTION..............................................................................................................................7

METHODOLOGY.............................................................................................................................8DataandDefinitions.............................................................................................................9

ENGAGEMENTFACTORSFORRURALNURSES................................................................................12AQueenslandExperience....................................................................................................14

POSTGRADUATEEDUCATIONANDTRANSITIONALPROGRAM.................................................14Photovoice&CulturalAwareness........................................................................................14AnexperiencefromOntario,Canada...................................................................................14PostGraduatePrograms......................................................................................................15SimulationTraining.............................................................................................................16

ORIENTATION..........................................................................................................................16CulturalOrientation............................................................................................................17

MENTORING&PRECEPTORSHIP...............................................................................................17AnUmbrellaReviewofMentorship,Preceptorship&ClinicalSupervision...........................17

FINANCIAL&NON-FINANCIALINCENTIVES...............................................................................17IMMERSION(Students&Academics).......................................................................................17

AnAustralianexperience-Gippsland..................................................................................18ImmersionforAcademics;aWesternAustraliaExperience.................................................18

CONTINUOUSPROFESSIONALDEVELOPMENT..........................................................................18PalliativeCare.....................................................................................................................18AnOverseasExample–Norway..........................................................................................19

ENGAGEMENTTHROUGHRECRUITMENT......................................................................................19POSTRETIREMENT..............................................................................................................20

ENGAGEMENTTHROUGHWorkforceRetention............................................................................20AnOverview........................................................................................................................20PROFESSIONALRECOGNITION.............................................................................................21ADVANCEDPRACTICE(NURSEPRACTITIONER)....................................................................21DECISIONMAKING..............................................................................................................22AnOntario,CanadaExperience...........................................................................................22MULTI-DISCIPLINARYCOLLABORATION...............................................................................23CULTURALENGAGEMENT....................................................................................................24CulturalEngagement–ByNativeAmericanNurses.............................................................24FLEXIBLEWORKFORCE.........................................................................................................25

DISENGAGEMENTFACTORSFORTHERURALNURSINGWORKFORCE............................................26

EDUCATIONALCHALLENGES..........................................................................................................26UNDERGRADUATESTUDENTPLACEMENTS..........................................................................27ATasmaniaExperience........................................................................................................27POSTGRADUATEEDUCATION&TRANSITIONALPROGRAM................................................27CONTINUOUSPROFESSIONALDEVELOPMENT.....................................................................28FlightNursesExperiences....................................................................................................28

RETENTIONCHALLENGES..............................................................................................................29INADEQUATEPROFESSIONALRECOGNITION.......................................................................30


DISEMPOWERMENT............................................................................................................30AMentalHealthExample....................................................................................................30AMidwiferyExample..........................................................................................................31TheWesternAustralianExperience.....................................................................................31LACKOFAUTONOMY..........................................................................................................31

DISENGAGEMENTTHROUGHCORPORITISATION&ECONOMICRATIONALISATION.......................32AnInternationalExperience-AppalachianMountains,WestKentucky...............................32

CONCLUSION................................................................................................................................33

References....................................................................................................................................34


EXECUTIVESUMMARY

IstheruralnursingandmidwiferyworkforceinAustraliaengagedordisengaged?

CRANAplus recognised there has been a void in professional representation within the health

industry for rural nursing and commissioned the Rural Nursing Project, with the aim to identify

opportunities forCRANAplus tobemore relevant forNursingworking in rural contextofpractice.Contemporary professional practice clearly recognizes the respective nursing and midwifery

professions; this paper draws on the parallels between nursing and midwifery. The project

commencedinJuly2016withtheundertakingofanarrativeliteraturereview.Theliteraturereview

hasexploredthefactorsofengagementanddisengagementofruralnurses,inbothAustraliaandthe

developedcountries,namely,NewZealand,Canada,UnitedStates,GreatBritainandScandinavia.

In the narrative literature review undertaken for CRANAplus, 700 abstracts and 59 articles were

examined.Thesepapers indicated that thebedrockofour ruralhealthservices,nursing,hadbeen

suffering from the gradual withdrawal of structural supports for over twenty years. A change in

public policy from one of social welfare to a market economy caused the regionalisation and

rationalisationofhealthservices.Consequentlyhavinganegative impactontheHealthServicesof

smallercommunities,andsignificantlydeskillingofthelocalruralspecialistandgeneralistnurseand

midwife.Thusresultinginadisengagementofboththenursingandmidwiferyprofessionswithrural

Australia.

Thereviewedliteratureacknowledgedthattheruralnurse’sskillsencompassesabroadknowledge

andexpertisebase=generalistapproach.Graduatenurseswhohadbeguntheircareersintherural

areas, reported that they felt poorlyprepared through their undergraduate studies, andwerenot

able to meet the required breadth of skills as novice nurses. The rural nurse simultaneously

struggledwithrolecreepasaresultofcompetingdemandsofthehealthservice.Therewasaclear

lackofrecognitionandacknowledgementbytheemployeroftheextendedrolesoftheruralnurse

andmidwife.

The withdrawal of speciality care, including mental health and midwifery, has seen the slow

deskillingofpractitionersand,subsequently,theerosionofvitalandessentialservices.Nurseshave

expressedtheir lossofautonomywithin theirpractice.Thiswasparadoxical,consideringthemore

recent legislative changes to endorse the roles of the nurse practitioner and midwife. These

practitionerswereameanstoaddressthedeclineinruralhealthservices,particularlyinthesmaller

communitiesthatwereunabletorecruitproceduralmedicalofficers.Inflexibilitywithinworkplace


practices, was also a feature of the literature. Nurses sought a work life balance but with the

changesinrolesandthedemandsofwork,familyandlifestylewerecompromised.

Anotherdemand,whichhadbeenmadeon thenursingandmidwiferyprofessionsby theNursing

and Midwifery Board of Australia, was the requirement to provide evidence for undertaking

continuous professional development to maintain registrations. Rural nurses reported that their

preference for Continuing Professional Development (CPD) education was for onsite, face-to-face

training. Inhibitivefinancialandsocialandfamilyimpactstoattendtraining,washighlightedalong

withtheneedtogainmanagementsupporttobereleasedfromwork.

Significant advances in information technology for training have included web-based training,

webinars,onlineresourcesandhighfidelitysimulationhasbeenacknowledgedasimprovingaccess

toongoingeducation,howeverunreliable internet connections impactedon theusefulnessof this

form of training. Acceptance of this delivery mode was variable amongst the generational

workforce.

Arecognisedstrengthoftheruralareaswasthevibrantrelationshipsandinformalnetworks,which

weredeeplyembeddedwithinthelocalculture.Thisprovidedameanstointegrateandsupportthe

new graduate entering theworkforce and thosewho had been recently recruited from overseas.

Thisalso led topositivemethodsof collaborationwithcommunitymembersandwasextended to

multidisciplinary health teams to ensure that a breadth of services was available to the rural

communitiesinAustralia.


INTRODUCTION

CRANAplus, commissioned the Rural Nursing Project with the aim to identify opportunities for

CRANAplus to be more relevant to Nurses working in the rural context of practice, including

recruitment,retention,professionaldevelopmentopportunitiesandpathwaysforRuralNursing.

A narrative literature review was undertaken to explore the means of engagement and

disengagementofruralnursesandmidwivesinthedevelopedcountriesofAustralia,NewZealand,

Canada,UnitedStates,GreatBritainandScandinavia.Inthecontextofthisstudyweacknowledged

the role of the duel qualified Registered Nurse and Registered Midwife who have traditionally

provided maternity care in the rural setting. This paper principally refers to nursing roles unless

Midwifery was specifically included in the articles identified in the Literature Review. The

engagementofnursesintotheruralsectormayhaveoccurredwhencareeroptionswereintroduced

to them as high school students.While there is a dearth of literature regarding the role of rural

nursesattheendoftheircareerandintoretirement,Volt&Carson,2014indicatethattherearea

rangeofopportunities for remoteareanurses tobe re-engagedwith theirworkplaces inbothpre

andpostretirement.Enrollednurseswereincludedinthisreview.

Thereisaplethoraofresearch,studiesandcommentariespublishedonruralnursingandmidwifery

both internationally and in Australia this is evident by the number of articles accessed and

subsequently reviewed. The literature clearly described the continued struggle by an ageing rural

workforce that isdisadvantaged throughhaving fewer resources to serveacross vast geographical

distances.(K.L.Francis&Mills,2011;McCool,Guidera,Reale,Smith,&Koucoi,2013;Nowrouzietal.,

2015;Welfare,2014,2015;Yates,Usher,&Kelly,2011).

Historicallytheruralnursingandmidwiferyworkforcehave,utilisedadvancedclinicalpracticesand

have been responsible for initiating interventions and treatments. Currently many of these

procedures require credentialing or endorsements by local health services or nationally by the

NursesandMidwiferyBoardofAustralia (NMBA).Bishetal (2015)describesanddefines therural

nurse as specialist generalist who uses the ‘knowledge of the community [that] they reside in

combinedwith advanced clinical skills to provide a nurse led service that responds to the health

needsoftheircommunityinacontextualway’.(Bish,Kenny,&Nay,2015)p382

Thispaperfocusesonthe49articlesretrievedwithinthereview.Throughathematicanalysis, five

main themes presented themselves, which included education, recruitment, retention,


organisational and government policies that support neoliberalism and corporatisation. Within

thesemain themes,multiple subgroupswere then identifiedandhavebeendescribedwithin this

paper. These are presented in Diagram 1 page 8. Within the themes an overview and detailed

examples are provided for the reader to consider the current position for nurses and midwives

workingintheruralsector.Toprovideacontextforthereview,dataonthecurrentruralnursingand

midwiferyworkforce(2015)isintroduced,followingapresentationonthemethodologyutilisedfor

thisreview.

METHODOLOGYA narrative literature reviewwas undertaken to investigate factors, which engages or disengages

nursesworkingintheruralareasindevelopedcountriesofAustralia,NewZealand,UnitedStatesof

America, Canada, Scandinavia and Great Britain. Each county shared similar professional, social,

politicalandenvironmentalsettings.

Inclusion criteria for the review included both qualitative and quantitative publications in print

between January2014andAugust2016.TheGriffithUniversity Library cataloguewasutilisedand

includedtheScienceDirect,ProQuest,ScopusandCINAHLdatabasesfortheliteraturesearch.

Toachieveabroadperspectiveandunderstandingofruralnursing,thekeywordsselectedincluded

the terms: professional identity, collegiality, motivation, career, membership, professional

development, professional needs and graduate programs These were then matched against the

primarysearchtermsofruralandnursingandmidwifery.

Theliteraturesearchincludedatotalof748publicationswithafinal49articlesacceptedthatmetall

the inclusion criteria. A thematic analysis was then undertaken of these articles to identify what

engagesordisengagestheruralnurseormidwife.(Braun&Clarke,2006)Fivemainthemesbecame

evidentwithin the researchand these included:professionaldevelopment, recruitment, retention,

organisational and government policies that support neoliberalism and corporatisation. These

themes were then further explored and sub groups were identified which described the existing

context of rural nursing and midwifery, which is embedded within the national political, social,

environmental and industrial milieu of the twenty-first century. To further develop the

presentation, within the thematic sub groups, examples have been provided of the extensive

researchundertakenasidentifiedwithinthisliteraturereview.

To contextualise and gain an understanding of the Australian rural nursing workforce a brief

overviewisprovidedasameansofintroductiontothestudyandisasfollows.


THERURALNURSINGANDMIDWIFERYWORKFORCEINAUSTRALIA

Theruralandregionalareasrepresent27%ofthetotalAustralianpopulation.Theseareasareknown

to have higher rates of illness and mortality. They also experience greater barriers in accessing

services through geographical distances and reduced access to health services.(Welfare, 2014)

NursesandmidwivesmakeupthelargestworkforceinruralandremoteAustralia.(Bishetal.,2015;

Mills,Francis,McLeod,&Al-Motlaq,2015)TheseprofessionsinAustraliacontinuetobechallenged

byanageingworkforce.(Pugh,Twigg,Martin,&Rai,2013).

DataandDefinitions

TheAustralianInstituteforHealthandWelfare(AIHW),publishthe‘NationalHealthandWorkforce

Series’includedwithintheannualpublicationofthe‘NursingandMidwiferyWorkforce’Report.This

publication utilises the Australian Standard Geographical Classification (ASGC) employed by the

Australian Bureau of Statistics (ABS) to classify five major geographic regions; Major cities, Inner

regional,Outer regional,RemoteandVery remote.(Pink,2011).For thepurposesof thispaperwe

haveusedtheclassifications:InnerandOuterRegions,todefinetheruralareasinAustralia.

The AIHW uses data obtained from the workforce survey provided annually by the Nurses and

Midwifery Board of Australia (NMBA) of all nurses andmidwives at the time of their renewal of

registration.Thedatahasbeenutilisedinthisstudytodescribecurrentruralworkforcefornurses.

ThetablebelowisadaptedfromtheAIHWpublication,‘NursingandMidwiferyWorkforce2012’and

the 2015workforce data sets published online. There is evidence of a small increase in the rural

workforcesince2012andalsoa7.55%increaseinthefiftyplusagegroup.Theaveragetotalweekly

hoursworkedremainedsimilarfrom2008to2015whichwasalsocomparabletothehoursworked

bynursesandmidwivesinthemajorcities.(Welfare,2013,2015)

Inner&OuterRegional 2008 2012 2015Number 79,414 77,742 80,445AverageAge(Years) 45.50 46.35 46.35Age50andover(%) 38.55 45.35 46.1Averageweeklyhoursworked 33.15 33.00 33.1FTErate(per1,000population) 1,148.55 1,101.03 1,093.75Population(total) 6,347,479

Table 1: Employed Nurses andMidwives for rural areas (Inner andOuter Regional) selected characteristics2008–2012AdaptedfromNursingandMidwiferyWorkforce2012(Welfare,2013)page31andtheNationalHealthWorkforceDataSet2015DetailedSupplementaryTables(Welfare,2015)


Enrolled Nurses constitute 29.06% of the rural nursing workforce and work similar hours to the

RegisteredNurse.Thisisdescribedthroughdataadaptedfromthe2014NationalHealthWorkforce

DataSet(AIHW)asprovidedinthetablebelow.(Welfare,2015)

InnerRegional OuterRegional TotalNumber RegisteredNurses 42,925 19,402 62,327EnrolledNurses 12,122 5,996 18,118AverageHoursWorked AverageRegisteredNurses 32.9 34.3 33.6EnrolledNurses 31.1 31.9 31.5

Table2:EmployedRuralNursesandMidwives2015asadaptedfromtheNationalHealthWorkforceDataSet2015DetailedSupplementaryTables(Welfare,2015)

Theageingandcontractingoftheruralworkforcehasbeenreflectedinternationallyincountriesas

theUnitedStatesofAmericaandCanada(K.L.Francis&Mills,2011;McCooletal.,2013;Medves,

Edge,Bisonette,&Stansfield,2015;Nowrouzietal.,2015;Yatesetal.,2011).

Extensive research has been undertaken over the past twenty years to address these ongoing

changesinthehealthworkforceinanattempttomeetthedemandsofthoselivingwithintherural

areas.Thefollowingdiscourserepresentsathematicanalysisofwhatengagesordisengagesnurses

working in the rural areas of Australia, USA, Canada, New Zealand, Great Britain and Scandinavia

withinthepastfiveyears(2011to2016).Thediagramasfollowsrepresentsthethematicanalysisof

theliteraturewiththepresentingthemesofengagementanddisengagement,whichfocusesonthe

elementsofeducation,recruitment,retention,governmentpolicyandcorporatisation.


ENGAGEMENTFACTORSFORRURALNURSESENGAGEMENTTHROUGHEDUCATION

Anoverview

Engagement factors for the nursing andmidwifery workforce, includes both an international and

Australianperspectiveforabreadtheducationalopportunities.Thisbeginswiththeintroductionof

nursingandmidwiferytolocalhighschoolstudentstopromotetheseprofessionsaswellasbeinga

process for potential recruitment to undergraduate university education. (Benavides-Vaello et al.,

2014)

The placement and support for undergraduate students is also a means to recruit nurses and

midwivesbackintothecountry. Itrequiresstrongsupportsthroughaclinicalfacilitatorembedding

the student into awelcoming community and recognising the social qualities of bothprofessional

and personal relationships,which are the cornerstone of a rural community.(Smith, Lloyd, Lobzin,

Bartel,&Medlicott,2015)

Theprovisionof a transitional andpost graduate training thatutilisesdifferent formsofmedia to

supportdevelopment,suchashighfidelityequipment,butprioritisesopportunitiesforlocalfaceto

faceeducation.(Missen,Sparkes,Porter,Cooper,&McConnell-Henry,2013).

Strong orientation programs facilitate ameans to provide an overview of theworkplace but also

introduce thenurseandmidwife to the community. This includes culturalorientation forentering

indigenous communities but also for overseas workers who require clarity in communication

protocolsandsocialetiquette.(Dywili,Bonner,Anderson,&O'Brien,2012;Yonge,Myrick,Ferguson,

&Grundy,2013)

Preceptorship and the role of clinical facilitatorswere viewed as the preferredmeans to support

students and employees for undergraduate, transitional and orientation programs. Mentoring

created extra demands on the mentor who also had demanding clinical roles. It was the

responsibility of the University to employ clinical facilitators, this strategy was promoted by the

students andhosting rural hospital. Both graduates andundergraduates sought to receive regular

constructivefeedbackonperformanceasameanstoachievingtheirsetgoals.(Gray&Brown,2016;

Mbemba,Gagnon,Paré,&Côté,2013;Pront,Kelton,Munt,&Hutton,2013)

Furthermoretheprovisionoftransitionalandpostgraduatetrainingthatutiliseddifferentformsof

media,suchashighfidelityequipment,tosupportdevelopment,didnotnegatetheimportancefor

localface-to-faceeducation.(Missen,Sparkes,Porter,Cooper,&McConnell-Henry,2013).


To provide a purview of rural life and prospective work for students and employees, the use of

immersion through bush camps or study days was exercised. Immersion activities were an

instrumentforacademicsseekingtoimprovetheirunderstandingandinvolvementinstudentrural

placements, (Deutchman, Nearing, Baumgarten, &Westfall, 2012; Page et al., 2016; K. P. Sutton,

Patrick,Maybery,&Eaton,2015)

Allnursesandmidwivesarerequiredtocompletemandatedprofessionaldevelopmenthourstogain

renewal of their registration with the Nurses and Midwifery Board of Australia. To achieve this

nurses indicated their preference for local learning activitieswith face to face inmultidisciplinary

teamswithclinicalplacementsasopportunitiesforskillandknowledgedevelopment.(Phillips,Piza,

&Ingham,2012)

HighSchoolPrograms

A successful photovoice projectwas undertaken in a two-week summer residential programwith

HispanicandNativeAmericanhigh school students. Thiswas included in localpipelinesprograms,

whichhadbeenestablished,toincreaseanddiversifyapplicantsfromhighschoolstoapplyforlocal

nursingundergraduateprograms.(Benavides-Vaelloetal.,2014)

PlacementforUndergraduateStudents

Placements for undergraduate students in the rural areas provided ameans for promoting future

recruiting opportunities whilst introducing the students to generalist nursing and the rural

community.IntheUnitedKingdomastudywasundertakenwherethreephaseswereidentifiedfora

nurse’splacement.This included the initial transitionalphasewhereadislocation frompeers, and

clinical staff occurred. The second phase was one of negotiation where the student sought the

support, guidance and protection of a senior student or mentor. The final phase was relocation

(engagement)whenthestudentwasenabledtoaddressanynegativeexternalattitudesandresume

theirroleasastudent,despiteincivilitywithintheworkforce.(Thomas,Jinks,&Jack,2015)

ASouthAustralianExperience

A study conducted in a regional hospital in South Australia, acknowledged the impact the rural

environment had on the undergraduate student and his / her placement and their learning

experiences.Thisincludedbothprofessionalandsocialrelationshipssharedwhenworkingandliving

inthecountryandsomeconfoundingofboundaries.(Prontetal.,2013)


Smithetal (2015) includedfivesmallhospitalsandaregionalcommunityhealthservice inaSouth

Australian study. The aim was to increase the number of university student placements by the

enhancement of the clinical facilitator’s role. An increase in undergraduate placements was

undertaken in direct response to an anticipated shortfall in the rural nursing and midwifery

workforce.(Smithetal.,2015)

AQueenslandExperience

Amidwiferycontinuityofcarestudentplacement,inaruralQueenslandMidwiferyGroupPractice,

afforded high levels of satisfaction. This was linked to a close mentorship and positive clinical

learningculturebuiltwiththecaseloadmidwives.FundingfromDepartmentalscholarshipsfreedthe

student to focus on the placement, without the need to financially support themselves. (20%)of

participantsindicatedtheywouldseekfutureemploymentinaregionalhospitaland25%indicated

they would work within a hospital based MGP. (Carter, Wilkes, Gamble, Sidebotham, & Creedy,

2015)

POSTGRADUATEEDUCATIONANDTRANSITIONALPROGRAM

Photovoice&CulturalAwareness

A photovoice study was conducted with graduates and their preceptors in Western Canada, in

Alberta and Saskatchewan. (Crow, Conger, & Knoki-Wilson, 2011) This was reported as a very

positivemeansfornewgraduatestorecord,withtheirpreceptors,theirjourneyoflearningbasedin

aruralhealthsetting.Feedbackwithinthisresearchfromthegraduatesincludedtheimportancefor

themtobeanacceptedasvaluedteammembers,whichenabledthegraduate,todeveloptrustand

confidencewiththeirpreceptorsthroughthisprocess.

AnexperiencefromOntario,Canada

AstudyundertakeninruralsouthernOntario,Canada,includednurseswhowereinterviewedinfive

smallcommunityhospitals(10to53beds).Thestudyincorporatedeightinterventionsinresponseto

therecommendationsderivedfromthereport.ThenursingworkforceinruralOntarioincluded58%

ofstaffworkingfulltime(eightortwelvehourshifts)withonly2.5%ofstaffworkingcasually.This

mayreflectthecurrentpracticesforboth48%ofurbanandruralnurseswhochoosetoworkpart-

timeinAustralia.(Welfare,2013).

Otheraspectsof thisstudyworthnotingwerethe interventionsundertakenwithin thestudy, that

werederivedfromnursingfeedbackandincludedmainlyeducationalstrategies.Theeducation


strategies incorporated various courses; two day mock trauma, critical care education and an

orientationcourse.External fundingwassought forcontinuingstaffdevelopment,an investigation

for a potential library service and an application for academic and certificate development. Two

further recommendations includedstaffappreciationeventsandapreceptor recognitionprogram.

(Medvesetal.,2015)Thesewerealso reflected,but in lessdetail, in theAustralian literaturewith

nursing responses formethods to improve retentionofnurses througheducation. (K. L. Francis&

Mills,2011)

PostGraduatePrograms

Learningneeds identified fornewgraduates included the requirement foradefinitively structured

program, extending to two years as one suggested option. Graduates also needed structural

empowerment,with resources, toenable themtoachieve theirgoalswithin the firstyear.Clinical

scenarios with high-fidelity simulation was also recommended to enable a positive learning

environment and to develop confidence in clinical care.(Missen,McKenna, Beauchamp,& Larkins,

2016)Afocusontimemanagement,prioritisingclinicaldutiesanddevelopcommunicationskillsto

support difficult conversations with medical officers were also identified as key areas for

development.Graduatesalsoneededtolearnhowtoprovideacomprehensivehandoverandthese

learning experiences were all required to be undertaken within the first twelve months. The

graduatesalsoneeded tobe rosteredappropriatelywith theirpreceptor, receive regular feedback

and reflect on their performance. These were essential to achieve a positive and safe learning

environment.(Mellor&Greenhill,2014)Ultimatelyacollaborativeapproachbetweenhealthservice

management, clinical staff, educators and academicswas vital to support a successful transitional

graduateprogram.(Bennett,Barlow,Brown,&Jones,2012;Lea&Cruickshank,2015).

Research undertaken by Stewart et al (2012) on an 2008 online post graduate mental health

program forGriffithUniversity (Queensland) ruraland remote interprofessional students, included

nurses, social work / human services and psychology. This study indicated that the online

environmentprovided flexibilitybut the lackof face-to-faceenvironment inhibited learning. There

was a need for work base placements and assessments to ensure the development and

consolidation of skills and knowledge.Whilst the interdisciplinary approach was appreciated, the

need for discipline specific training was also acknowledged. (Stewart, Fielden, Harris, &Wheeler,

2012)


SimulationTraining

The use of simulation training in an Australian rural health service was reported as a means to

provide local on site education to nurses in emergency management. Included were three

researchersasobserversandanassessor,twoactorstoplaytheroleofthreepatients,andavideo

recordingforthethreecasesmanagingadeterioratingpatient. Feedbackwasprovidedtoeachof

theresponsegroupsthroughreplayingthevideo,debriefingandevaluatingtheprogram.(Missenet

al.,2013)

ORIENTATIONOrientation for all students, graduates and new staff was critical for the introduction to the

workplace and procedures, including systems for communication and safety. Orientation into the

ruralareawasalsoreputedtobeameanstointroducethecommunitytothenurseandmidwifeand

embed the employee into the culture. This included those nurses and midwives recruited from

overseastomeettheincreasedworkdemandsofacontractingworkforce.(Bourgeault,Neiterman,

&LeBrun,2011;Pughetal.,2013).

A literature reviewwas undertaken by Dywili et al (2012), on the experience of overseas trained

health professionals (OTHP) in rural and remote areas ofAustralia, Canada,NewZealand,UK and

USA. The researchers screened 1,652 documents between the years 2004 - 2011 with the final

inclusion of 17 documents of which 2 focused specifically on nursing. (Dywili et al., 2012) These

authors emphasised that the orientation program and integration into the local community was

crucialtothesuccessofemployeeappointments.Includedwithintheorientationanintroductionto

local communication protocols was seen as essential to support safe practice. Cross-cultural

communication was also perceived as a challenge for both staff and overseas trained health

professional. These professionals may have had a different worldview and so can present with

different professional values, which may have created a sense of 'cultural separateness and

otherness'.(Bourgeaultetal.,2011)(p179)

Rural communitieswere perceived aswelcoming and accepting, but they also possessed a strong

desiretoseethattheirculturewasrespected.Thenewnursesandmidwivesneedtobesupported,

tointegratebothintotheworkplaceandthelocalcommunity.Somenursesandmidwivesfeltvery

isolated fromtheirown familiesand friendswhenrelocating toa ruralarea.Specialistnursesmay

also be challenged through the change to generalist care and require additional support through

orientation. Offering onsite education and access to professional development and support as a


meanstoembedtheoverseasnursewithintheworkplaceandensurecontinuityofservice.(Dywiliet

al.,2012)

CulturalOrientation

An emphasis on the community ethos was also the fulcrum for the attraction of nurses to the

countrywith theNavajoAmerican Indians.A culturalorientationprogramwasprovided forurban

nursesandutilisedamentortoculturallyconnectthenursetothecommunity.Thisassistedwiththe

socialisation requiredbetween the traditional (Navajo)andwesternnursingworldviews. (Yongeet

al.,2013)

MENTORING&PRECEPTORSHIPThe need to mentor new nurses and midwives was highlighted, not only for the undergraduate

placements, but also for new appointments, including those who undertook transitional

postgraduatetraining.Thenewgraduateappointedtoaruralhealthfacilityalsorequiredabroader

scope of practice than what was provided through their undergraduate program. Graduates

expressedthattheyfeltoverwhelmedandabandonedifacomprehensiveorientationandbuddying

systemhadnotbeenprovidedatcommencement.

AnUmbrellaReviewofMentorship,Preceptorship&ClinicalSupervision

Mbemba et al (2013) undertook an umbrella review of 5 articles from 517 publications. These

articlesidentifiedfourmainthemesthat includedsupportiverelationshipsinnursingasmentoring,

preceptorshipandclinicalsupervision.Preceptorshipinvolvedclinicalstaffwhilstmentoringincluded

facultystaff,whichwereabletoprovideonetoonesupportforthestudentnurse.Avitalresourceis

thementor for rural nursing staff, contrary toGray andBrown (2016)who reported that regional

nursementors did not have the resources or timewhilstworking in a busy rural hospital.(Gray&

Brown,2016;Mbembaetal.,2013;Prontetal.,2013)

FINANCIAL&NON-FINANCIALINCENTIVESMbenbaet al identified that financial incentiveswere themost commonly reported incentives for

recruitment and short-term retention. Non-financial incentives included improved working and

housingconditionsmayhaveagreaterimpactonretentionofruralnursesthanfinancialincentives.

(Mbembaetal.,2013)

IMMERSION(Students&Academics)The use of immersion weeks or study days for undergraduate students and academics gave a

purviewofrurallifeandwork.Thesestrategieshavesupportedfuturerecruitmentandplacements

forundergraduatenurses.


A means to support interdisciplinary relationships included an immersion week held by the

UniversityofColoradoDebver(USA),forstudentsinselectedruralcommunities.Thisenhancedtheir

understandingandinvolvementinthecultural,economicandenvironmentalaspectsoflifeandwork

inthecountry.Itprovidedopportunitiesforstudentstoconsiderfutureemploymentandaddressed

ruralrecruitmentdemands(Deutchmanetal.,2012).

AnAustralianexperience-Gippsland

A similar model was used in Gippsland to promote future employment opportunities. A pilot

program to attract undergraduates from rural areas undertaking their allied health and nursing

studies inMelbourne,withintheirvacationperiods,toparticipate inafive-dayruralmentalhealth

program in Gippslandwas undertaken. The five-day program included seminars, workplace visits,

plenarydiscussionsandsocialoutings.Twocourseswereprovidedin2010andalongitudinalstudy

wasalsoundertaken.Preandpostparticipantevaluation surveyswere conductedand indicateda

strong effect on student attitudes and intentions in working in rural mental health (K. Sutton,

Maybery,&Moore,2012).Localstakeholderinvolvementwasalsoverypositive.Thefinaloutcomes

of this studywaspublishedbySuttonetal (2015)andprovided two findings. Firstly, a short-term

recruitment intervention can affect attitudes towards pursuing a rural career in mental health.

Secondly,anemersionexperienceforstudents,canchangetheirknowledgeandunderstandingofa

futurecareerandworkavailableintheruralmentalhealthsector(K.P.Suttonetal.,2015).

ImmersionforAcademics;aWesternAustraliaExperience

An example of an academic emersion model in the rural areas was undertaken by the Western

AustralianCentreforRuralHealth(WACRH),whoinvitednurses,alliedhealthacademicsandclinical

placementcoordinatorstoanAcademicBushCamp.Thecampmodelledstudentprogramswiththe

purpose to increase rural studentplacements. Theprogramconsistedof visiting rural and remote

learningsites,walkingtoursandpresentationsbytheWACRH.(Pageetal.,2016)

CONTINUOUSPROFESSIONALDEVELOPMENT

PalliativeCare

Aruralpalliativecareprogramwasresearchedthroughanintegrativeliteraturereviewandincluded

an international perspective by encompassing Canada, UK, America and Australia. The authors

sought to address five questions, which included; the impact of CPD on improving patient care,

learningformatsthatbestsuitedtheneedsofruralnurses,theuseoftechnology,andthebarriers

andfacilitatorsfortraining.


The outcomes of this study highlighted the inadequacy of research undertaken to measure the

impact of CPD on patient care. Stakeholders also needed to be includedwithin the planning and

developmentphaseofthetraining,whichwasunderpinnedbyadultlearningprinciples.Therewasa

dearth of information available on the use of information technology (IT) for rural palliative care

training. A recommendation from this report was to include IT competencies within the rural

palliativecareprogram.ThechallengesandbarrierstoprovidingCPDforruralpalliativecare,mirrors

theruralsector.Therewaslimitedmeansofaccessbecauseofgeographicaldistances.Thecostsfor

accommodation and travel and the inability to roster relief staff to provide cover were barriers.

Preferenceswereforlocallearningactivities,withfacetofaceandmultidisciplinaryapproachesto

supporteffectivenetworkingwhilsttraining. Clinicalplacementswithspecialistservicestosupport

thedevelopmentofskillsandknowledgewerealsoseenasapriority.(Phillipsetal.,2012)

AnOverseasExample–Norway

One overseas study conducted in Norwaywas able to describe, quite a different context to rural

Australia.Similaritiesthoughdidincludebarriersfornursesandmidwivesintheruralsectorseeking

to access CPD whilst being geographical isolated. Norway however did not require nurses or

midwives to complete CPD for ongoing licensure. Nurses who were seeking to specialise in

anaesthetics,operatingtheatreorintensivecareforuniversityhospitalemploymenthowever,were

thenrequiredtoattendappropriateeducation.

Intheruralormunicipalareas inNorway,nursingcareincludedgerontic,publichealthandmental

health care. Midwifery practice was also declining in the rural areas, similar to other developing

countries, as birthing moved towards the University hospitals or regional cities. In this study, a

surveywas conductedwith 233 former graduates of theArticUniversity ofNorway, between the

years of 1990 – 2011with 56% of these graduateswho completed their Continuous Professional

Education (CPD)within186programs. ThiswasseenasapositiveoutcomeasCPDwasseenasa

meanstonetworkandretainnursesintheArticareaswhilstalsoachievingdiversificationinhealth

care.(Skaalvik,Gaski,&Norbye,2014)

ENGAGEMENTTHROUGHRECRUITMENTAnOverview:

Recruitmenthasbeenanongoingchallengefortheruralsector.Opportunitiestorecruitbeginwith

studentsinhighschool,throughimmersionprojects,invitingstudentsandprospectiveemployeesto

attended workshops located in rural communities. This principle


was sustained throughundergraduateplacements andby attractingnurses andmidwives into the

country for theirgraduate transitionalprograms.Allof thesearepotential recruitingopportunities

andneedtobeappropriatelyresourcedwithwellresearchedprogramsthatincludefacetofacelocal

services, clinical facilitators funded through universities and regular feedback and support for

professionaldevelopmentplans.

Anothermeanstoconsideristheopportunityforinvitingthosewhohavechosentoretireorleave

their professions by offering incentives that are attractive and relevant. Rural areas are attractive

andprovideameanstowelcomebacknursesandmidwivesintothelocalworkforce.(Voit&Carson,

2014)

POSTRETIREMENT

Astudyintoretirement intentionsandpostretirementemploymentopportunitieswasundertaken

throughavoluntarysurveywithnursesemployedintheNorthernTerritory(NT).Thiswasnotarural

project but included respondents who were either urban based (53.8%) or remote (46.2%). The

studyidentified8postretirementoptionsthatcouldbetransferrabletoruralnursing&midwifery.

Two cohorts of nurseswere surveyed; thosewho intended to retire andnot seek re-employment

and those who were considering post retirement opportunities. The opportunities for post

retirement included; financial incentives for re-employment, opportunities tomentor, undertaking

seasonalemployment, gradual reduction inworkhours, actasaNT representative,be involved in

researchandpolicydevelopmentorjobshare.Barriersidentifiedwithinthestudy,includedcurrent

policies intheNorthernTerritorythatrequiredfull timeappointmentandtheselectionofrecently

qualifiednursesandmidwives.ThecompulsorylegislatedretirementintheNorthernTerritoryis65

yearsofageandcurrentlytherearenopoliciesforcontinuingtheengagementoftheolderperson.

(Voit&Carson,2014)

ENGAGEMENTTHROUGHWORKFORCERETENTIONAnOverview

Retention of staff is dependent on a web of interlaced factors which includes the need for both

midwives and nurses to be recognised for their work and standing in the community. The Nurse

Generalisthasabreadthofskillsandknowledgethatexceedsthegeneralistroleintheurbansetting.

Thereisaclearneedbythenurseandmidwifetoberecognisedandtofunctionautonomously,with

theunderlyingsupportofmanagersandgovernmentpolicymakers(Hildingssonetal.,2016).


Theroleofnursepractitioners,nurseledclinicsandmidwiferycasemanagersisameanstoensure

thathealthservicesremaininthesmallerruralcommunities.(K.Francisetal.,2014).

Informal and formal networking and working collaboratively in interdisciplinary teams has been

strengthintheruralandremoteareas.Thisispartofbeingcommunityandisanincentivetolivingin

thecountryasitprofessionally,personallyandculturallyembedstheworkerintothelocalworkplace

andtown.(Cox,2003;Crotty,Henderson,&Fuller,2012;Jesse&Kirkpatrick,2013)

Flexibility inclusiveof opennessofmanagement, funders andpolicymakers to support alternative

models in nursing andmidwifery led care is a valued requirement by rural nurses andmidwives.

Recognising thegeneralist rolesof thenurseaswell as identifying that changes inworkloadswith

increasedresponsibilitiesneedstobesharedorredistributed.(K.L.Francis&Mills,2011;Pughetal.,

2013)

PROFESSIONALRECOGNITION

ResearchwasundertakentosurveymidwivesinNewZealand,SwedenandAustraliatomeasurethe

degreeofautonomy,managerialandprofessionalsupport,skillsandresources.Thestudyrevealed

thatNewZealandandSwedenprovidedastrongerprofessionalidentityasthemidwifeworkedmore

autonomouslycomparedtotheAustralianmidwife,whowasbasedinamorefragmented,medical

modelwithinahospitalenvironment.Australianmidwiveshadretainedan'industrialapproach'to

theirprofessionaldevelopmentwhilsthavingaformalcareerpathwaywhenemployedbythepublic

sector.Howeverthesemidwiveswerefirmlyenmeshedwithinanursinghierarchyandthisimpacted

ontheirpromotionalopportunities.

New Zealand midwives were provided with supportive mentoring in their pre-registration and

transitional programmes. These midwives have a large workforce of self-employed midwifery

models that encompassed a full scope of practicewith significant opportunities for development.

However Swedenmidwives, though autonomous in their practice,work in a fragmented prenatal

and birthing model and have low opportunities for education post registration to re-enter the

workforce. The midwifery employer in Sweden does provide further education but there is no

registrationrequirementforongoingeducationasregulatedinAustralia.(Hildingssonetal.,2016)

ADVANCEDPRACTICE(NURSEPRACTITIONER)

Theliteraturereviewhighlightedtheneedforbothnursesandmidwivestobeabletoberecognised

for their roles as practitioners and to be able to perform autonomously. The role of the nurse

practitioner andmidwifery caseloadmanager enable the retention of vital services to the smaller


rural communities in the absence of procedural medical officers being recruited to the country.

Disempowermentwas identifiedasameans toundervalue thenurse.Thiswas in response to the

fragmentationof thespecialistmentalhealthrole.Asenseof ‘abandonment’bymanagementand

policymakers,totheprofessionwasinterpretedbythementalhealthnurses. Theneedtoensure

sustainability and strength of the practitioner role was by improving undergraduate and

postgraduateeducationthusensuringabetterunderstandingoftherolebyotherdisciplines.

Midwivesandnursesinthecountryareoftenrecognisedforboththeirgeneralistandspecialistskills

andknowledge.However thebreadthof thegeneralist role,andgreaterworkloadcreatedgreater

stress. (K. L. Francis & Mills, 2011; McCool et al., 2013; Pugh et al., 2013) The role of sole

practitionersfornursingandmidwifery,includingnursepractitioners,midwiferycaseloadmanagers,

nurse-ledclinics,hasalsobeenameanstoenhanceworksatisfaction.Theadvancedenrollednurse

role has also supported professional advancement and provides recognition for rural practice.

Obstaclesandbarrierstoachievingrecognitionandsupportforadvancednursingandmidwiferyled

practicearenotconfinedtotheObstetricorMedicalCollegesandAssociations. StateandFederal

governments with the required legislative changes, public sector managers and executives are

neededtoprovideleadershipandfundingintheadvancementoftheseroles.

Theprovisionofpostgraduatestudiesforruralnursestoqualifyasnursepractitionersisameansto

address the inequality of access to local health services.Nurse Practitioners are able to diagnose,

treat,referandprescribemedicationsandthis isawelcomedresourceforthosecommunitieswho

are experiencing difficulties in attracting and retaining general practitioners and allied health.(K.

Francis et al., 2014) These can include practitioners who have provided a breadth of specialist

services including aged care, emergency, mental health, community health and chronic disease

management.

DECISIONMAKING

AnOntario,CanadaExperience

The College of Nurses of Ontario, Canada, undertook a self-administered questionnaire with 45

RegisteredPracticeNurses(RPN)whohelda2-yearDiplomaandworkedin5communityhospitals.

The RPN reported to the RegisteredNurse, andwas similar to the role of the Australian Enrolled

Nurse. The Canadian rural workforce was experiencing similar conditions to Australia: staff

shortages, high turnover, ageing staff approaching retirement, andwith fewer graduates entering

the labour force. This studywas able to identify that thosehavingworkednine to eighteen years


weremore likely to remainwithin theworkforce. The RPN’swithmore than thirty years ofwork

experienceweremorelikelytoretireorleavebecauseofincreasingworkloads.RPN’salsoindicated

theirdesiretobeincludedinthedecisionmakingprocesswhichledtoahigherjobsatisfactionanda

lowerlevelofworkstress.(Nowrouzietal.,2015)

NETWORKING

Networking was also a key strategy used by both urban and rural health workers. A qualitative

research study, conducted in a country region in South Australia, highlighted the importance of

informalsocialnetworksformentalhealthpractitioners.(Crottyetal.,2012)Practitionersthatwere

interviewed includedmental health nurses. They identified informal networking to be ameans to

develop strong ties between professionals and to socially imbed themselves into the local

community, this strengthened and sustained the localworkforce. Conversely, rural networks have

diffuse role boundaries with less separation between the professional and personal identity. This

diffusionmakesthehealthworkermorevisibleandeasilyaccessibletothecommunity.Networking

hasadownsidefornewworkersenteringtheruralsector,astheexperienceofacceptancebytheir

peerscouldbeperceivedasmoredifficult, initially therefore leading to the inability to share their

ownexperiencesandperspectiveseasily.

Newcastle University developed a research protocol to facilitate effective interprofessional

relationships through defining a framework for an acute or community setting. This protocol

includedafunctionalroleforclinicians,managementandpolicymakerproviders.Theprotocolwas

located in a centre or practice based location with nursing, allied health, medical or non-

professionals. The protocol used individual interviews, focus groups and document analysis to

supportcollaborativeprofessionalrelationshipstoimprovecommunicationandfunctionsacrossthe

disciplines.Itwasproposedthatthisresearchwouldsupportthefunctionandcohesionoftheteam

andsosubsequentlyimprovejobsatisfactionthroughminimisinginterprofessionalconflict.Itwould

alsoreducehealthcarecostsbyreducingfutureadmissionsandtheturnoverofstaff.(Mitchelletal.,

2013)

MULTI-DISCIPLINARYCOLLABORATION

Providing strong collaborative multidisciplinary relationships was achieved through: formal

professionalnetworking,informalsocialcommunication,andcontactsbythenurselivingintherural

areas. Rural townships are renowned for their kinship and support for integrating new health

workers into their communities. The collaborative role, within multidisciplinary teams was well


embedded in the fabricofeachruralcommunity.Thishasbeenheraldedas themeanstoaddress

not only the health needs for the rural areas but also the workforce maldistribution and

shortage.(Mitchelletal.,2013)

Theneedforintragroupandintergroupcollaborationandcommunicationbetweenmultidisciplinary

orinterdisciplinaryteamswasanissuesharedbybothurbanandruralpractitioners.(Cox,2003)This

wasdescribedbytwoteamsofurbanandruralmidwivesinScotlandwhorelateddifferencesintheir

understandingofriskassessmentanddecisionmakingforthetransferofawoman in labourtoan

urban tertiary hospital. (Harris et al., 2011) Intradisciplinary or interdisciplinary collaboration also

requiredanunderstandingofthecomplexitiesbyeachhealthproviderandameanstodeliverand

providecaretotheclient,patientorwoman.

CULTURALENGAGEMENT

Cultural engagement has been provided through comprehensive orientation programs to embed

newnurses intothecommunityandprovideframeworkstoguideandassistthenewworkers.The

training can also be enhanced by being placed, directly within a cultural community or using

alternativeeducationmediums to support learning.Theuseofphotovoicewasameans to record

thejourneyforthenursebeginninginanewroleandhowthiswassharedthiswiththementor.The

recruitment of overseas nurses and midwives also required, the orientation to include local

communicationprotocolsto identifyprofessionalvaluesandworldviews,whichmaynotbesimilar

tothatoftheruralcommunity.

The midwifery and nursing care provided to the Hispanic and Native American communities,

includedtheCherokeeandLumbee Indians,wasdonewithinadiversecrossculturalenvironment.

Thiswas done to prepare through education the nurses andmidwives entering this cross-cultural

workforce. Thiswasundertakenforstudentmidwives intheEastCarolinaUniversityandwasa4-

prongedcourse,whichincludedaculturalcompetencycourse,Spanishlanguagetraining,traditional

healingpracticesandanopportunitytoundertakeglobalawarenesswithinaninternationalproject.

The cultural competency course was embedded in the midwifery course and included cultural

immersionexperiencesinMexicoandHaiti.(Jesse&Kirkpatrick,2013).

CulturalEngagement–ByNativeAmericanNurses

IntheEleventhAnnualIndianNursingEducationConference,aplenarysessionwasconductedwith

participantfocusgroupstoconsidertheNativeAmericanCultureConceptualFrameworkandhowit

applied to their nursing practice and research. The Framework included 7 important dimensions;


caring, tradition, respect, connection, holism, trust and spirituality all embedded within nursing

practice.Outcomes from these group focus sessionswere set against the framework and used to

integratetheculturalframeworkintopractice.Nursingresearchsupportedthemeanstoinvestigate

andexploretheNativeAmericanhealthrelatedphenomenaandthemeanstodevelopaculturally

appropriateservicewithinavailablehealthresources.(Lowe&AnneNichols,2013)

FLEXIBLEWORKFORCE

There is a need for a flexible ruralworkforce, open to considering alternativemodels of care and

break with the traditional biomedical (illness) model. Models for community based and client

centredcarealsomeetswith thephilosophyof indigenousandnon-indigenousruralcommunities.

The need to recognise the generalist roles for the rural nurse but also recognise the demands of

increasingworkloadsandthedistributionofwork.Thisincludestherolethenursebeingmentorfor

undergraduatestudentsinadditiontotheirclinicalloading.TheuseofUniversityfundedpreceptors

forundergraduateplacements in ruralhospitals is thepreferredmodel to remove thedemandon

busy clinical staff toprovide the required coaching.(Dywili et al., 2012;K. L. Francis&Mills, 2011;

Pughetal.,2013)


DISENGAGEMENTFACTORSFORTHERURALNURSINGWORKFORCE

EDUCATIONALCHALLENGESAnOverview:

Disengagementforruralnursingandmidwiferyiswellrepresentedintheliteratureandthisincludes

identificationofbarriers,which inhibit a rewarding learningandworkingenvironment. Aswell as

themeans to engage undergraduates in the workforce, there still remains barriers to supporting

studentsinruralplacementswhenresourcingisstretchedandclinicalworkloadsdemanding,aswas

theexperienceforsomeTasmaniannursepreceptors.(Zournazis&Marlow,2015)

Postgraduate transitional programs also experience challenges in resourcing regions that are

impacted through restructuring and diminishing infrastructure.(Lea & Cruickshank, 2015) The

graduatealsohasdemandsplacedonthemtohaveabroaderscopeofpracticeandresponsibilities

than prepared by university training leaving graduates overwhelmed with a feeling of being

abandoned. (Bennettetal.,2012;Mellor&Greenhill,2014)Thiswas furtheraggravatedbysenior

nurses expectations forwork readinesswhichwasbeyond the graduates skill level,which in turn,

becameabarriertothelearningenvironmentandnegativelyimpactedontheiradjustmenttorural

living.(Bennettetal.,2012;Ostini&Bonner,2012)

The requirement tomeetmandated hours of continuous professional development is a statutory

requirement for renewal of registrationby theNurses andMidwiferyBoardofAustralia. It is also

fraughtwith challenges for those living andworking in the rural sector.Distances, costs for travel

andaccommodation,seeking leaveapprovalandhavingaccess tospecialistcoursesarechallenges

that continue for the rural nurse andmidwife. Understanding the requirements for developing a

professionaldevelopmentplanandusingreflectivepracticewerealsoconcernsthatneedtobemet

bytheprofessionsworkingintheruralsector.(Brideson,Glover,&Button,2012)


UNDERGRADUATESTUDENTPLACEMENTS

ATasmaniaExperience

Preceptors, similar to the mainland, predominantly provided the Tasmanian experience for rural

nursing support. The nurse preceptorswere also under pressurewith extended clinicalworkloads

whilst they provided educational assistance. The University of Tasmania School of Nursing and

Midwifery had provided monthly video conferencing and a website to facilitate networking and

informationsharingpriortostudentplacements.Itwasacknowledgedthatsomesitesdidnothave

the technological aptitude for this equipment. The preceptors stated that clinical pressures

negativelyimpactedonthembeingabletoattendthevideoconferences.(Zournazis&Marlow,2015)

POSTGRADUATEEDUCATION&TRANSITIONALPROGRAM

Postgraduate transitional programs provided in rural areas were the focus of four studies

undertakeninthreestatesofAustralia:NewSouthWales,SouthAustraliaandVictoria.Thestudies

includedfocusgroupsandinterviewswithgraduatenursesandpreceptors.(Lea&Cruickshank,2015;

Mellor & Greenhill, 2014; Ostini & Bonner, 2012). This research acknowledged the distinct

challenges and resources required to provide rural graduate programs, often in regions suffering

from diminishing infrastructure and experiencing significant restructuring within their local rural

healthservices.(Lea&Cruickshank,2015)

The vocational demands on graduates who chose to relocate to the country following the

completionoftheirdegree,couldbedifficultastheywereoftenrequiredtohaveabroaderscopeof

practice than their urbanbased colleagues. Thebroader scopeof practicewas theundertakingof

concurrentmultiplenursingroleswithinanacute,agedcareoremergencysettingoftenwithoutthe

supportingskillmix.Coupledwiththeexpectationstofulfiltheseroles,whilstonlyhavingaccessto

anon callmedical officerwasdeemed stressful. The graduates reported that theywere generally

underpreparedforpracticeandoftenfeltoverwhelmedandabandonedwithoutbeingaffordedthe

required clinical supervision. They often received only adhoc education, because of busy clinical

settingsandinadequateavailabletimefortraining.(Bennettetal.,2012;Mellor&Greenhill,2014).

Senior nursing staff also expected awork readiness beyond the graduates’ level of education and

experience.Thiswasparticularlydifficultforthegraduatenursetoaddresswithinthefirstthreeto

sixmonthsofemploymentas theyhadonlybegun toconsolidate theirpractice. (Ostini&Bonner,

2012)Thepresenceofnegativitybyolder,experiencedhospital trainednurseswasharmful to the


graduate’slearningenvironment.Thenegativitytowardsthemactedasabarriertosocialiseandbe

included within the fabric of the workplace and rural community. (Bennett et al., 2012; Ostini &

Bonner,2012)

CONTINUOUSPROFESSIONALDEVELOPMENT

Continuousprofessionaldevelopment(CPD)wasalsoameanstoengageandretainruralnursesand

midwives.CPDisastatutoryrequirementbytheNursesandMidwiferyBoardofAustralia(NMBA)to

maintain registration. Rural nurses andmidwives experienced barriers to accessing CPD, including

geographical distances, costs of accommodation, ability to be released from work, particularly if

backfill forrosterswasrequired. Gainingresourcesupportbymanagementwasand isanongoing

challenge.

The advancement of electronic and web based education has improved access for rural staff to

educationbutthiswasdependentongoodinternetconnectionsandtheabilityforthesenursesand

midwivestoworkwithtechnology.Resistancetothisformofeducationbyoldernurses,whowere

unfamiliarwithtechnology,preferredface-to-faceeducationasasuperiorformoftraining.Provision

oflocaltrainingwasseenasthebestoptionwhenthealternativeincludedtravellinggreatdistances

andbeingseparatedfromtheirfamilies.

FlightNursesExperiences

InacasestudyconductedbytheFlindersUniversityin2009,flightnurses(FN)employedbytheaero

medicalorganisationsweresurveyed. This study identifiedbarriersandvariances inachieving the

requiredmandatedtwentyhoursofCPDbytheNursesandMidwiferyBoardofAustralia(Bridesonet

al.,2012).Thebarriersflightnursesexperiencedwerereportedassimilarchallengesfacedbyrural

nurses; being released from their rosters, travelling significant distances required to attend the

training and inadequate financial support. Flight nurses indicated there was minimal specialist

educationavailableonaeromedicalmidwifery.

Thestudyalsohighlightedthedifferencesbetweenwhattheresearcherscalleda ‘workerattitude’

anda ‘professionalattitude’whensomeflightnursesdidnot incorporatereflectivepracticewithin

their learning. Itwasalso identifiedthattherewaspoormotivationtomeetCPDrequirementsas

80% of the participants did not have a professional development plan and they considered such

trainingasoptional. Thescopeofpractice fortheflightnurse is toworkautonomously.Theflight

nursewasrequiredtoprovideemergencycareforwomenduringtheflight.Theywerenotafforded

the professional support from a second midwife. However respondents did volunteer some


suggestionsthatcouldimprovetheiraccesstotrainingwhichincludedaccessingelectronicformats

suchase-learninganduseofsimulationequipment(Bridesonetal.,2012).

RETENTIONCHALLENGESAnOverview:

Ruralnursesandmidwivesfeltundervaluedwithimposedchangestotheirgeneralistandspecialists

roles. This has created a sense of abandonment felt by nurses and midwives from other health

disciplines,management,fundersandpolicymakers.Thiswasexperiencedinthemilieuofasector,

which continued to place increasing demands and expectations on a contracting and ageing

workforce. There was an expectation for the practitioner to meet multiple demands whilst

acknowledgingthelossofrolesandnomeanstoaddresstheinequitiesinserviceprovision.Thiswas

describedbybothmentalhealthworkersandmidwives,anddivisivewhenurbanandruralsectors

competedforthesameresourcesandfunding.Thiswasparticularlythecaseforthegrowingnursing

specialities and midwifery led models (Crowther & Ragusa, 2011; Yates, Kelly, Lindsay, & Usher,

2013;Yatesetal.,2011).

Theseexperiencescreatedasenseofdissatisfactionintheworkplace.Increasingworkdemandswith

minimalmanagement support, lead towork-life imbalance,particularlywhen familydemandsalso

increased.(K.L.Francis&Mills,2011;McCooletal.,2013;Pughetal.,2013)


INADEQUATEPROFESSIONALRECOGNITION

Studiesundertakenwithruralmidwivesandnurseshaveshownthat,withpoorworkchanges,role

ambiguity, intra and interprofessional conflict, inadequate performance feedback and insufficient

recognitionbymanagement,allleadstodissatisfactionwithworkingconditions.(Yatesetal.,2013;

Yatesetal.,2011)

DISEMPOWERMENT

AMentalHealthExample

ThiswasexemplifiedthroughthegroundedresearchundertakeninWaggaWagga,NewSouthWales

withmentalhealthnurseswhowereinterviewedandexpressedthattheyfeltundervalued.Thiswas

attributed tobeingmultifactorialandwaspre-emptedwith theclosureof theNSWMentalHealth

NursingRegister in early 1990's. The lossof themental health specialist-nursing role to generalist

undergraduatetraining,andthechangefromhospital tocommunitycare,wereperceivedasgreat

lossestotheprofession.Theongoingnaturalattritionofthespecialistmentalhealthnurse,leadto

theabsenceofsuitablyqualifiedreplacements.Instead,alliedhealthworkerssubsumedtheseroles.

This produced a feeling of abandonment from government policymakers, linemanagers and the

allieddiscipline.Management,however stillexpected thementalhealthnurse todo the 'grunt'of

thework.Withacaseload,whichhadincreasedinacuityintheruralareas,manyclientswerealso

beingassessedwithdualdiagnoses.

The mental health nurses also considered that, in comparison with the urban areas, they were

unable to access asmany support services in psychology and drug and alcohol. They were often

heavily involved in responding to crises at the cost of providing therapeutic intervention to local

clients.Thisincreasedtheirsenseofbeingundervaluedasaprofessionalandasavaluedcommunity

member. (Crowther& Ragusa, 2011) Ameans to address this inequity by theUniversitieswas to

include a more comprehensive content to the undergraduate mental health subjects as well as

increasethenumberofpostgraduatecoursesintherelevantareasofmentalhealthpractice.


AMidwiferyExample

Ruralmidwives also felt undervalued in their work environment when the birthing services were

shiftedtotheregionalfacilities.Thosewhowerequalifiedinbothnursingandmidwiferybecamede-

skilled, as they no longer supported women through their pregnancy and birth. Midwives

experienced conflict at times when required to provide care for both the acute patient and the

womaninlabour.Asthiswasresourceandtimeintensiveandonlyaddedfurtherstresstothework

environment.(Yatesetal.,2013;Yatesetal.,2011)

This was also the experience for international midwives located in the rural areas of the United

Kingdom,UnitedStatesofAmericaandCanada.Globalmaternityreformwastosupportcontinuity

of care for the woman within these countries and to promote this model of care, with some

solutions being provided to support their midwives. The support included access to professional

development,provisionofregularfeedbackfromseniorprofessionals(management,administrators

andobstetricians),andopportunitiestoworkwithinthemodels.(K.L.Francis&Mills,2011;McCool

etal.,2013)

TheWesternAustralianExperience

TheNursesandMidwiferyOfficeundertookasurveywithmidwivesemployedinWesternAustralia.

23%ofallrespondentslivedintherural,regionalorremoteareas.50%ofallrespondentsindicated

theirintentionofleavingworkwithinfiveyearsbecauseofawork-lifeimbalance,careerchangeor

familycommitments.Midwiveswerealsoseekingaworkforcethatwasflexible,providedreasonable

caseload work and provided locally based, professional development to negate the high costs in

travelanddisruptiontotheirfamilylife.Webbasedlearninghoweverwasnotthepreferredformof

choice by senior midwives and the younger, less experienced midwives, preferred to work in

midwiferyledmodels.(Pughetal.,2013)

LACKOFAUTONOMY

Lack of professional autonomy was also reflected in a midwifery pilot study undertaken by the

University of Pennsylvania School of Nursing at an International Confederation of Midwives

Conference(2010).30%ofmidwiferyparticipants,whowerebasedintheruralareas,soughtboth

recognition and autonomy in their workload from their managers and local doctors. A barrier

identifiedinachievingthiswastheclearlackofadministrativeandpoliticalsupport.Theauthorsalso

highlightedasignificantshifttoadefensive,medicalapproachbymidwivesbecauseofthepervasive

fearoflitigationandsubsequentlossoflicensureandlivelihoods.(McCooletal.,2013)


DISENGAGEMENTTHROUGHCORPORITISATION&ECONOMICRATIONALISATIONAnOverview;

The role of neoliberalism and the rationalisation of government supported services to the rural

areas, continues to impact on the retention and recruitment of rural nurses andmidwives (West,

2013).ChangesinGovernmentpublicpolicyhasleadtocentralisationandregionalisationwiththe

rationalisationofhealthservicesandthesubsequentwithdrawalofservicesbeingavailableforthe

smallerruralcommunities.Thishadnegativeimplicationsforthenursingandmidwiferyworkforce,

having experienced changes in their own workplaces and roles. Through inadequate resourcing,

significant gaps ineducation, and inadequateworkforce retention strategies, theprofessionshave

suffereddisengagement.

AnInternationalExperience-AppalachianMountains,WestKentucky

West(2013)described,fromahistoricalperspective,thechangesinanorganisationalculturewithin

apoor,undevelopedruralareaintheAppalachianMountainsofEasternKentucky.(West,2013)A

communitybasednursingandmidwiferyservice,initiallyfoundedandfundedbyonewomaninthe

early1900’s,experiencedchangestobecomeacorporatized,fiscallybasedservice.Theruralnurses

andmidwiveswhowere initially employed,were autonomous and utilised their advanced clinical

skillswithasmall-centralisedservice.Thisgrewtoonehospitalwithsixnursingoutposts.Changes

occurred when interventions by the United States government, to address poverty in the

Appalachian area, were managed remotely by Washington economists. The interventions

implemented were without an understanding of the isolated areas and led to a service, which

became fragmented, medicalised and changed through economic rationalisation. The author

interviewedboththeformernursesandmidwivesemployedunderthepreviousbenefactorandthe

new corporate structure. The former nurses acknowledged the changes to the organisation and

theirdisempowermentwiththe lossofautonomyandabilitytoprovideadvancedpractices (West,

2013).


CONCLUSIONThe developed countries share similar factors, which has contributed to the engagement and

disengagement of rural nurses. Themix of government and employer policy and fundingmodels,

recruitment and retention incentives and educational resourcing determines the extent of

engagementbynursesandmidwiveswithintheirprofessionalpracticeandruralcommunities.Given

that,itisimportanttorecognisedtherewerelimitationswithinthisliteraturereviewontheextent

of specific rural government policies and initiatives,which have effected the engagement of rural

nurses.

Contemporary professional practice clearly recognises the respective nursing and midwifery

professions, thispaperdrawsontheparallelsbetweennursingandmidwifery.Howeverthispaper

hasprincipally referredtonursingrolesunlessmidwiferywasspecifically included in the identified

articlesintheliteraturereview.Whennursesandmidwivesarerecognisedashealthpractitionersin

their own right,whoareempowered to fulfil their generalist or specialist roles, engagement then

happens. When Universities appropriately resource and employ clinical facilitators to support

undergraduatestudentplacements, the future ruralworkforce is strengthened. Whentransitional

graduate programs offer comprehensive; and supportive mentors, who also assist to embed the

nurseormidwife into the local community; retentionof staff is a likelyoutcomeandengagement

happens.Withtheuseofimmersion,photovoice,culturalintegrationandotherinnovativemeansto

attractandretainstaff,theruralworkforcebecomestrulyengaged.

There is a great strength that emanates from rural communities being open and relational. Rural

health services attract, support and also embed their nurses and midwives within their local

communities.Thehealthserviceswhoprovideflexibleworkingconditionsandasupportive,learning

environment;attract,activelyengageandretainstaff.Provisionofeducationalprogramstailoredto

theneedsofthepractitioner,whichareprovidedlocally isameanstofurtherdevelopandmature

theworkforce.

Employers, governmentpolicymakers, funders, educational bodies and leaderswithin thenursing

andmidwiferyprofessionswilldeterminethefutureoftheruralworkforce.Thereisalwaysaneed

for strong nursing leaderswho are prepared to advocate for the professions and ensure they are

appropriatelyresourcedtomeetfuturedemands.


REFERENCESBenavides-Vaello, Sandra,Katz, JanetR.,Peterson, JefferyChaichana,Allen,CarolB.,Paul,Robbie,

Charette-Bluff, Andrea Lelana, & Morris, Phyllis. (2014). Nursing and Health Sciences

Workforce Diversity Research Using PhotoVoice: A College and High School Student

Participatory Project: 1. Journal of Nursing Education, 53(4), 217. doi:10.3928/01484834-

20130326-02

Bennett,Paul,Barlow,Veronica,Brown,Janie,&Jones,Debra.(2012).Whatdograduateregistered

nurses want from jobs in rural/remote Australian communities? Journal of Nursing

Management,20(4),485-490.doi:10.1111/j.1365-2834.2011.01254.x

Bingham, Mary-Grace. (2016). Silent, Slow Disengagement of the Australian Rural Nursing and

MidwiferyWorkforce.UnpublishedPaper.CRANAplus.Adelaide,SouthAustralia.

Bish, Melanie, Kenny, Amanda, & Nay, Rhonda. (2015). Factors that influence the approach to

leadership: directors of nursing working in rural health services. Journal of Nursing

Management,23(3),380-389.doi:10.1111/jonm.12146

Bourgeault, IvyLynn,Neiterman,Elena,&LeBrun,Jane.(2011).Midwivesonthemove:Comparing

therequirementsforpracticeandintegrationcontextsforinternationallyeducatedmidwives

in Canada with the U.S., U.K. and Australia. Midwifery, 27(3), 368-375.

doi:http://dx.doi.org/10.1016/j.midw.2011.03.010

Braun, Virginia, & Clarke, Victoria. (2006). Using thematic analysis in psychology. Qualitative

ResearchinPsychology,3(2),77-101.doi:10.1191/1478088706qp063oa

Brideson,Genevieve,Glover,Pauline,&Button,Didy.(2012).FlightnursesinAustralia:Maintaining

theirmidwiferycompetence--acasestudy.ContemporaryNurse:AJournalfortheAustralian

NursingProfession,43(1),121-130.doi:10.5172/conu.2012.43.1.121

Carter,AmandaG.,Wilkes,Elizabeth,Gamble,Jenny,Sidebotham,Mary,&Creedy,DebraK.(2015).

Midwiferystudents׳experiencesofaninnovativeclinicalplacementmodelembeddedwithin

midwifery continuity of care in Australia. Midwifery, 31(8), 765-771.


Cox, K. B. (2003). The effects of intrapersonal, intragroup, and intergroup conflict on team

performance effectiveness and work satisfaction.Nursing Administration Quarterly, 27(2),

153-163.

Crotty,MikailaM.,Henderson,Julie,&Fuller,JeffreyD.(2012).Helpingandhindering:Perceptions

of enablers and barriers to collaboration within a rural South Australian mental health


network. Australian Journal of Rural Health, 20(4), 213-218. doi:10.1111/j.1440-

1584.2012.01282.x

Crow,Karine,Conger,MargaretM.,&Knoki-Wilson,Ursula.(2011).Mentorshipfornursinginarural

area: a program for success forworkingwith diverse populations.Online Journal of Rural

Nursing&HealthCare,11(2),43.

Crowther, Andrew John , & Ragusa, Angela Theresa. (2011). Realities of Mental Health Nursing

Practice in Rural Australia. Issues in Mental Health Nursing, 32(8), 512-518.

doi:10.3109/01612840.2011.569633

Deutchman, Mark E., Nearing, Kathryn, Baumgarten, Brenda, & Westfall, John M. (2012).

Interdisciplinaryruralimmersionweek.RuralandRemoteHealth,12,2045.

Dywili, Sophia, Bonner, Ann,Anderson, Judith,&O' Brien, Louise. (2012). Experienceof overseas-

trainedhealthprofessionals inruralandremoteareasofdestinationcountries:Aliterature

review. Australian Journal of Rural Health, 20(4), 175-184. doi:10.1111/j.1440-

1584.2012.01281.x

Francis,Karen,Boyd,Michal, Latham,Heather,Anderson, Judith,Bradley,Angela,&Manners, Jan.

(2014).A regionalapproach to theeducationofnursepractitionercandidates tomeet the

health needs of rural Australians. Contemporary Nurse, 49(1), 27-34.

doi:10.1080/10376178.2014.11081950

Francis,Karen. L.,&Mills, Jane.E. (2011). Sustainingandgrowing the ruralnursingandmidwifery

workforce:Understandingtheissuesandisolatingdirectionsforthefuture.Collegian,18(2),

55-60.doi:http://dx.doi.org/10.1016/j.colegn.2010.08.003

Gray, Olivia, & Brown, Donna. (2016). Evaluating a nursementor preparation programme.British

JournalofNursing,25(4),212-217.

Harris,FionaM.,vanTeijlingen,Edwin,Hundley,Vanora,Farmer,Jane,Bryers,Helen,Caldow,Jan,..

.Tucker,Janet.(2011).Thebuckstopshere:MidwivesandmaternitycareinruralScotland.

Midwifery,27(3),301-307.doi:http://dx.doi.org/10.1016/j.midw.2010.10.007

Hildingsson,Ingegerd,Gamble,Jenny,Sidebotham,Mary,Creedy,DebraK.,Guilliland,Karen,Dixon,

Lesley,...Fenwick,Jennifer.(2016).Midwiferyempowerment:Nationalsurveysofmidwives

from Australia, New Zealand and Sweden. Midwifery, 40, 62-69.


Jesse,D.Elizabeth,&Kirkpatrick,MaryK. (2013).Catching theSpiritofCulturalCare:AMidwifery

Exemplar. Journal of Midwifery & Women’s Health, 58(1), 49-56. doi:10.1111/j.1542-

2011.2012.00226.x


Lea, Jackie,&Cruickshank,Mary. (2015).Supportingnewgraduatenursesmakingthetransitionto

rural nursing practice: views from experienced rural nurses. Journal of Clinical Nursing,

24(19-20),2826-2834.doi:10.1111/jocn.12890

Lowe, John, & AnneNichols, Lee. (2013). Utilisation of a Native American nursing conceptual

framework: Implications forpracticeand research [online].Australian JournalofAdvanced

Nursing,,31(2),13-22.

Mbemba,Gisèle,Gagnon,Marie-Pierre,Paré,Guy,&Côté,José.(2013).Interventionsforsupporting

nurseretentioninruralandremoteareas:anumbrellareview.HumanResourcesforHealth,

11(1),44-44.doi:10.1186/1478-4491-11-44

McCool, William, Guidera, Mamie, Reale, Barbara, Smith, Andrea, & Koucoi, Jaclyn. (2013).

ProfessionalissuesrelatedtoobstaclestomidwiferypracticeintheAmericas:Apilotsurvey.

Midwifery,29(8),838-844.doi:http://dx.doi.org/10.1016/j.midw.2012.08.007

Medves,Jennifer,Edge,DanaS.,Bisonette,Linda,&Stansfield,Katherine.(2015).SupportingRural

nurses:SkillsandKnowledgetoPracticeinOntario,Canada.OnlineJournalofRuralNursing

andHealthCare,15(1),7-41.doi:10.14574/ojrnhc.v15i1.337

Mellor,Peter,&Greenhill, Jennene. (2014).Apatientsafety focusedregisterednurse transition to

practice program. Contemporary Nurse, 47(1-2), 51-60.

doi:10.1080/10376178.2014.11081906

Mills, Jane, Francis, Karen, McLeod, Margaret, & Al-Motlaq, Mohammad. (2015). Enhancing

computerliteracyandinformationretrievalskills:Aruralandremotenursingandmidwifery

workforce study. Collegian, 22(3), 283-289.

doi:http://dx.doi.org/10.1016/j.colegn.2014.02.003

Missen, Karen, McKenna, Lisa, Beauchamp, Alison, & Larkins, Jo-Ann. (2016). Qualified nurses'

perceptionsofnursinggraduates'abilitiesvaryaccordingtospecificdemographicandclinical

characteristics. A descriptive quantitative study. Nurse Education Today, 45, 108-113.

doi:http://dx.doi.org/10.1016/j.nedt.2016.07.001

Missen, Karen, Sparkes, Louise, Porter, Joanne, Cooper, Simon,&McConnell-Henry, Tracy. (2013).

Developing team based acute care scenarios: A rural hospital experience. International

EmergencyNursing,21(3),186-189.doi:http://dx.doi.org/10.1016/j.ienj.2012.08.002

Mitchell,Rebecca,Paliadelis,Penelope,McNeil,Karen,Parker,Vicki,Giles,Michelle,Higgins,Isabel,.

. . Ahrens, Yvonne. (2013). Effective interprofessional collaboration in rural contexts: a

researchprotocol.JournalofAdvancedNursing,69(10),2317-2326.doi:10.1111/jan.12083


Nowrouzi,B.,Rukholm,E.,Larivière,M.,Carter,L.,Koren, I.,&Mian,O. (2015).Anexaminationof

retentionfactorsamongregisteredpracticalnursesinnorth-easternOntario,Canada.Rural

andRemoteHealth,15(2),3191.

Ostini,F.,&Bonner,A..(2012).Australiannewgraduateexperiencesduringtheirtransitionprogram

in a rural/regional acute care setting. Contemporary Nurse : A Journal for the Australian

NursingProfession,41(2),242-252.

Page,AmyT.,Hamilton,SandyJ.,Hall,Maeva,Fitzgerald,Kathryn,Warner,Wayne,Nattabi,Barbara,

& Thompson, Sandra C. (2016). Gaining a ‘proper sense’ of what happens out there: An

‘AcademicBushCamp’topromoteruralplacementsforstudents.AustralianJournalofRural

Health,24(1),41-47.doi:10.1111/ajr.12199

Phillips, Jane L., Piza, Michael, & Ingham, Jane. (2012). Continuing professional development

programmesforruralnursesinvolvedinpalliativecaredelivery:Anintegrativereview.Nurse

EducationToday,32(4),385-392.doi:http://dx.doi.org/10.1016/j.nedt.2011.05.005

Pink, Brian. (2011). Australian Standard Geographical Classification (ASGC). Canberra, Australia:

Australian Bureau of Statistics Retrieved from

http://www.ausstats.abs.gov.au/ausstats/subscriber.nsf/0/32FBEDE1EA4C5800CA25791F00

0F2E1C/$File/att98dqt.pdf.

Pront,Leeanne,Kelton,Moira,Munt,Rebecca,&Hutton,Alison.(2013).Livingandlearninginarural

environment: A nursing student perspective. Nurse Education Today, 33(3), 281-285.

doi:http://dx.doi.org/10.1016/j.nedt.2012.05.026

Pugh, Judith D., Twigg, Diane E., Martin, Tracy L., & Rai, Tapan. (2013).Western Australia facing

criticallossesinitsmidwiferyworkforce:Asurveyofmidwives'intentions.Midwifery,29(5),

497-505.doi:http://dx.doi.org/10.1016/j.midw.2012.04.006

Skaalvik,MariWolff,Gaski,Margrete,&Norbye,Bente. (2014).Decentralizednursingeducation in

NorthernNorway:abasisforcontinuingeducationtomeetcompetenceneedsinruralArctic

healthcare services. International Journal of Circumpolar Health (Online), 73, 1-7.

doi:10.3402/ijch.v73.25328

Smith,Morgan,Lloyd,Gerry,Lobzin,Stefanie,Bartel,Christine,&Medlicott,Kym.(2015).Increasing

qualityandquantityofstudentplacements insmallerruralhealthservices: Itcanbedone.

AustralianJournalofRuralHealth,23(4),243-246.doi:10.1111/ajr.12165

Stewart,Victoria,Fielden,Jann,Harris,Michelle,&Wheeler,Amanda.(2012).Makingmentalhealth

practitioners workforce ready. The Journal of Mental Health Training, Education and

Practice,7(3),124-132.doi:10.1108/17556221211269938


Sutton, Keith,Maybery, Darryl, &Moore, Terry. (2012). Bringing them home: a Gippslandmental

health workforce recruitment strategy. Australian health review : a publication of the

AustralianHospitalAssociation,36(1),79.doi:10.1071/AH11003

Sutton,KeithP.,Patrick,Kent,Maybery,Darryl,&Eaton,Kaytlyn.(2015).Increasinginterestinrural

mental health work: the impact of a short term program to orientate allied health and

nursing students to employment and career opportunities in a rural setting. Rural and

RemoteHealth,15(4),3344.

Thomas, Juliet, Jinks, Annette, & Jack, Barbara. (2015). Finessing incivility: The professional

socialisation experiences of student nurses' first clinical placement, a grounded theory.

NurseEducationToday,35(12),e4-e9.doi:http://dx.doi.org/10.1016/j.nedt.2015.08.022

Voit,K,&Carson,DB.(2014).Post-retirementintentionsofnursesandmidwiveslivingandworking

intheNorthernTerritoryofAustralia.RuralandRemoteHealth,14.

Welfare,AustralianInstituteofHealthand.(2013).Nursingandmidwiferyworkforce2012.Canberra,

Australia: Australian Government Retrieved from http://www.aihw.gov.au/publication-

detail/?id=60129545333.

Welfare, Australian Institute of Health and. (2014). Australia’s health 2014. Canberra, Australia:

AIWH.

Welfare, Australian Institute of Health and. (2015). National Health Workforce Data Set 2015

SupplementaryTables.Canberra:Australian InstituteofHealthandWelfareRetrievedfrom

http://www.aihw.gov.au/workforce/nursing-and-midwifery/additional/.

West,Edith.(2013).History,organizationandthechangingcultureofcare:ahistoricalanalysisofthe

FrontierNursingService.JournalofInternationalWomen'sStudies,14,218+.

Yates,Karen,Kelly,Jenny,Lindsay,David,&Usher,Kim.(2013).Theexperienceofruralmidwivesin

dualrolesasnurseandmidwife:“I’dprefermidwiferybutIchosetolivehere”.Womenand

Birth,26(1),60-64.doi:http://dx.doi.org/10.1016/j.wombi.2012.03.003

Yates,Karen,Usher,Kim,&Kelly,Jenny.(2011).Thedualrolesofruralmidwives:Thepotentialfor

role conflict and impact on retention. Collegian, 18(3), 107-113.

doi:http://dx.doi.org/10.1016/j.colegn.2011.04.002

Yonge,Olive J.,Myrick, Florence, Ferguson, Linda,&Grundy,Quinn. (2013). "You have to rely on

everyone and they on you": interdependence and the team-based rural nursing

preceptorship.OnlineJournalofRuralNursing&HealthCare,13(1),4.

Zournazis, Helen E., & Marlow, Annette H. (2015). The use of video conferencing to develop a

communityofpracticeforpreceptorslocatedinruralandnontraditionalplacementsettings:


Anevaluation study. Nurse Education in Practice, 15(2), 119-125.

doi:http://dx.doi.org/10.1016/j.nepr.2014.11.004

factors effecting engagement or disengagement for rural nurses · literature review report factors...

Documents