INTRODUCTION

The provision of advanced rural nursing services withinprimary health care in New Zealand will be discussedwithin this paper. This discussion is based on a surveyundertaken by the author called Rural Practice NurseSkills Project, 1996.1 Among a variety of recommendationsset out from this survey to the then Southern RegionalHealth Authority (SRHA) was the development andimplementation of a postgraduate tailor-made clinicalcourse specifically aimed at rural nurses.

The process which unfolded will be discussed along-side the continued worldwide debate over the advancedrole of nursing and the future within rural primary healthcare.

Rural context in New ZealandRural primary health care in New Zealand is not immuneto the problems of retention and recruitment of generalpractitioners into rural practice. Primary health care inrural New Zealand has seen a move towards some ruralnurses providing an advanced nursing role. Rural nurseshave voluntarily, or out of necessity, taken on thisadvanced role. This has occurred because clearly a gapexists which has been left unfilled by other health profes-sionals.2 In addition, the lack of availability of otherhealth professionals and specialist practitioners in ruralcommunities places extra demands on the remaining ruralhealth practitioners. Rural nurses have filled this gapwhich has resulted in expectations from rural communi-ties, employers and government which warrant the devel-opment of the advanced role nursing has demonstrated itcan provide.

Advanced role of rural nursing

The advanced role of nursing has been described as beingmuch wider than increasing tasks.3 It is about the verycharacter of nursing. It is, therefore, important that rural

Aust. J. Rural Health (1999) 7, 253–257

Correspondence: Jean Ross, Lecturer, Primary Rural Health, andCo-director, Centre for Rural Health, St Elmo Court, PO Box 4345,Christchurch, New Zealand. Email: <jean.ross@chmeds.ac.nz>

Accepted for publication March 1999.

THE DEVELOPMENT OF THE ADVANCEDROLE OF RURAL NURSES IN NEW ZEALAND

Centre for Rural Health, Department of Public Health and General Practice, Christchurch School ofMedicine, University of Otago, Christchurch, New Zealand

ABSTRACT: This paper offers an informative insight into the development of the advanced role of rural nursingpractice in New Zealand. Provided is a futuristic vision of nurses’ contribution for the provision of primary ruralhealth care. The concept of advanced nursing practice will be discussed within the context of the interdisciplinaryhealthcare team. It is argued that as nurses take on advanced practice, it is essential they receive appropriate clinicaland theoretical skills to ensure they are in a position to provide competent and clinically safe, effective health care inan ethical, efficient manner. A description of a survey, undertaken by the author, studying rural nurses’ skills providesthe recommendation for the development of an appropriate postgraduate course at Masters level, designed specificallyfor primary rural nurses for the advanced role. The provision of this advanced education together with preparationand support, can pave the way for the highly skilled and knowledgeable nurses of the future working in collaborationwith the interdisciplinary rural healthcare team and rural community.

KEY WORDS: advanced role, education, research, rural nurse.

Jean Ross

International Perspective

254 AUSTRALIAN JOURNAL OF RURAL HEALTH

nurses should not be seen as medical substitutes by them-selves, their employers, government or rural communities.They are nurses practising in a way unique to the individ-ual conditions created by the rural health environment.4

Additionally, for many rural nurses, their daily prac-tice involves them in a number of community projects thatwould normally be considered outside the role of thenurse within the formal healthcare service. Rural nurseswork well beyond the limits of what is conventionallythought to be the scope of professional nursing practice.However, the challenge exists for nurses within theadvanced nursing role to continue to communicate thecentral value of nursing, that of caring.5 Whether thenurse’s scope of practice is classified as beginner, profi-cient or advanced, the nurse has the potential to enhancethe partnership between doctors, nurses and communities.This will occur as nurses are able to demonstrate andarticulate their role and contribution to patient care andcommunity health which may change the attitudes of otherdisciplines leading to collaboration and effective team-work.6 This collaborative relationship provides a ruralcommunity with the presence of both medical and nursingservices providing a primary healthcare team which canpresent to the patient and community a knowledge baseand set of skills that are more than one professional canprovide. In a team, the work-load is shared by a number ofhealth professionals with a range of expertise. Workingindependently but in collaboration is both the essence andthe challenge of effective team work. Each team memberis valued for their contribution, knowledge and clinicalexpertise. This is the philosophy underpinning teamwork.For the health service to be effective and efficient, themost appropriate health professional within the teamshould provide any given service to the community.7

Therefore, government and independent funding schemesfor the provision of health services should not berestricted to a particular discipline, for example, medicalpractitioners as is the case presently in New Zealand. Iffunding was directed for the health services provided bythe primary healthcare team, this in itself would benefitteam work and ultimately improve primary health care forwhich there are many advantages for the rural community,health professionals and funding agencies.

Rural nursing in New ZealandRural nurses in New Zealand are being invited to acceptchallenging rural positions in primary care. These posi-tions require the provision of 24 h emergency cover,advanced practice nursing skills and the ability to work ina team environment as demonstrated in a recent jobadvertisement (Fig. 1).8

As the advanced role of rural nurses develops, nurseswill need to acquire the necessary skills to undertake thisposition. It is, therefore, necessary to carefully plan andimplement appropriate educational courses to supportnurses in this role.

RURAL RESEARCH

In 1996, within my position of Rural Nurse CoordinatorSouthern Region, for the Centre for Rural Health, I under-took a research project. The research was commissionedby the Southern Regional Health Authority (now part ofthe Health Funding Authority, HFA) titled, Rural PracticeNurse Skills Project, 1996.1 The aim of this research wasto identify rural nurses’ roles and the problems and chal-lenges associated with this role.

Research designA questionnaire was used to obtain the informationrequired. This was thought to be the most appropriatemeans of acquiring the information. The questionnairecould reach all rural nurses within the southern region ofNew Zealand inviting them to participate in the research.This assisted in the efficiency of contacting a relativelysmall number of nurses over a large geographical area.

The questionnaire was divided into six categories: (i)practice/personal details; (ii) variety of rural nurse skillsand advanced role; (iii) first on-call emergency serviceprovided and appropriate preparation/backup/guide-lines/remuneration offered; (iv) education requirementsand appropriateness of obtaining continuing and postgrad-uate education; (v) telephone consultation; (vi) isolationfrom colleagues and peers, work environment, and contin-uing and postgraduate education.

FIGURE 1: Example of a job advertisement for an advanced

rural nurse (permission obtained from author).

PRACTICE NURSE

A full time practice nurse position is available at the Han-

mer Springs Medical Centre from mid April 1998.

This challenging rural position which entails some on call

work, requires an experienced person with advanced prac-

tice nursing skills. Further training will be given in radiog-

raphy, plastering and emergency care.

The person selected must be flexible and able to work well

in a team environment.

Applications close on March 27, 1998

ADVANCED ROLE OF RURAL NURSES IN NEW ZEALAND: J . ROSS 255

DatabaseThe database was obtained from the SRHA department ofthe primary care team which they acquired through a sur-vey in 1995. A list of all general practitioners by theirstreet addresses was used. Additional contactable man-ager’s addresses of employed rural nurses of Crown HealthEnterprises (managed by hospitals) was also obtainedthrough this method. A purely rural nurse database wasunobtainable.

Rural practice nurse questionnaireA questionnaire and covering letter was distributed bypostal service to all of the 69 rural general practiceswithin the SRHA, addressed to the practice nurse, on 1June 1996 to be completed by 30 June 1996. A pre-paid,self-addressed envelope was provided to return thecompleted questionnaire. It was left to the individualnurse whether she/he wished to remain anonymous or toindicate their personal details.

The total number of completed questionnairesreturned was 54; the total number of uncompleted ques-tionnaires returned was one; and the total number of ques-tionnaires not returned was 14.

DISCUSSION

The overall discussion points from the research fell intothree main areas: (i) isolation; (ii) variety of skills/expand-ing roles; and (iii) continuing education/professionaleducation.

IsolationIsolation for rural nurses appears to be the main issue ofconcern. Isolation implies isolation in the workplace, iso-lation from colleagues and peers and isolation from pro-fessional education. Additional to this, there is isolationfrom local family and friends within the rural communitysetting. It is essential that the factors that increase isola-tion are identified and strategies are built that will be

effective for its reduction. For example, building net-works, supporting one’s colleagues, providing educationrelevant for the rural health professional, and recognisingtheir contribution for the provision of health care.

Variety of skills/advanced rolesThe research indicates rural nurses provide a variety ofskills. These skills include a primary nursing role, acci-dent and emergency and health promotion. Other areasthat have been identified include: giving telephone adviceand consultation and management of health conditions.Many rural nurses provide additional service: for example,pregnancy care, family planning, cervical smear, breastself-examination, palliative care, public health and alsosee themselves as a resource health professional in thecommunity.

In addition, there are a number of other responsibili-ties required of rural nurses including: receptionist work,practice organiser, social worker and counsellor.

The total number of rural nurses who contributed tothis survey was 41, of which 10 nurses indicated they pro-vided 7 days a week, 24 h first on-call health provision. Inaddition, six rural nurses provided a 24 h first on-callhealth service overnight or at weekends, and 17 ruralnurses provided a first on-call health service during partof their working day. The total of rural nurses providing afirst on-call health service for all or part of their workingshift was 33 which was much larger than had beenexpected. The remainder was a total of nine rural nurseswho did not provide any first on-call health service(Tables 1, 2).

If one takes into consideration the isolation and thefactors that contribute to nurses’ isolation, further issuesare raised regarding the preparation rural nurses receivefor this first on-call health role. This research set out tofurther question the rural nurses’ role, the following ques-tions were asked: was the preparation to provide first on-call satisfactory; was there availability of satisfactoryemergency equipment for the nurses’ use; how did rural

TABLE 1: Summary of rural nurses’ skills in the southern region of New Zealand (n = 41)

No. on-call First daytime Weekends/nights 24 h cover all the time

(n = 9) (n = 17) (n = 6) (n = 10) Total

Practice, solo 22% 52% 50% 60% 48%

Practice, semi-solo 66% 47% 50% 40% 50%

Practice nursing skills 100% 94% 100% 100% 98%

Accident and emergency 100% 88% 100% 100% 95%

Health promotion 100% 94% 100% 100% 74%

Telephone advice 88% 94% 100% 100% 95%

Consultation and diagnosis – 65% 100% 70% 57%

256 AUSTRALIAN JOURNAL OF RURAL HEALTH

nurses maintain their skills, and what professional andlegal backup was available; are rural nurse skills andcompetencies reviewed on a regular basis; and are ruralnurses reimbursed for the on-call service they provide?

The research findings indicated an ad hoc systemoccurred leaving the rural nurse further isolated in thisadvanced role. Individual nurses were left to identify theirown training needs and acquire this knowledge in anunsupervised, ad hoc fashion.

Consequently, the nurse who provides an advancedrole requires adequate preparation within a safe, appropri-ate and effective environment. This will assist nurses toacquire the necessary skills and become confident andcompetent to practice at an advanced level. Nurses willthen be in an appropriately informed position to acknowl-edge their responsibilities and level of expertise. Addi-tionally, as nurses take on advanced roles, it is essentialthey are appropriately informed and knowledgeable ofwhat is required and expected of them by law, and thenursing profession. This will provide them for their futurepreparation and development for the advanced nursingrole. It cannot be overstated that accountability for nurses’actions is an integral part of professional development. Itis essential nurses have the necessary knowledge andskills to make complex decisions using their professionaljudgement and to be able to defend those decisions. Somerural nurses in New Zealand are performing an advancedrole for which they have little preparation and their com-petence may be uncertain.9,10 Additionally, nurses are putin a very difficult ethical situation because expectationsthat have developed over time from rural communities,medical colleagues and their own personal and profes-sional expectations may be in conflict with the dutiesunder the New Zealand Crimes Act, 1996, section 155.11

Clinical tailor-made courseThe data from the Rural Practice Nurse Skills Project,1996,1 indicated there was significant demand for post-graduate clinical training for rural nurses. This trainingcould assist rural nurses to gain the advanced level ofskills now required to meet the challenges and problems

associated with this role. Ongoing financial commitmentsince 1995 from the then SRHA (now National HealthFunding Authority) has assisted in the development of aMasters level postgraduate clinical course designed forrural nurses.

Throughout 1997, this course was developed. Thedevelopment took into consideration the opinions of therural nurses of the southern region (some rural nurses whohad contributed to the initial research in 1996) and theinternational literature for nurses providing advancedskills. This included educational and clinical require-ments for the advanced nurse practitioner role.12–14 Theestablished course titled ‘Advanced Rural Primary Nurs-ing’ comprises three parts:

Module 1—Multidisciplinary Clinical Guidelines:Understanding and Application.

Module 2—Advanced Rural Primary Care includingPrimary Response in Medical Emergencies (PRIME).

Module 3—Advanced Health Assessment (mental andphysical examination for rural nurses) and advanced nurs-ing roles.

Throughout the course, the development and theory ofadvanced clinical practice is discussed.

This postgraduate Masters course was offered for thefirst time in 1998. The 15 nurses who completed it did nothave an undergraduate degree. That, in itself, was a chal-lenge from the point of view of university and academicrequirements.

However, I believe if we are to recognise the advancedclinical role of rural nurses, then it is essential nurses areprovided with appropriate support to be educated at theclinical and theoretical level equal to their practice.

It is my belief the advanced clinical role of ruralnurses is a model which will set the scene for advancednursing practice in New Zealand. This model will benefitrural practitioners, rural communities, government anduniversities to capitalise on the advances rural nurseshave developed over the years for the provision of ruralprimary health care. Additionally, this can only enhancethe collaboration and understanding of the advanced roleof rural nurses by medical colleagues, government, educa-

TABLE 2: Rural nurses, first on-call health role (n = 41)

No. on-call First daytime Weekends/nights 24 h cover all the time

(n = 9) (n = 17) (n = 6) (n = 10) Total

First on-call – 100% 100% 100% 79%

While working – 100% 83% – 52%

Evening – – 67% – 9%

Weekend – – 100% – 14%

All the time – – – 100% 24%

ADVANCED ROLE OF RURAL NURSES IN NEW ZEALAND: J . ROSS 257

tional providers and rural nurses themselves. This canlead to the development of a full collaborative model, pro-viding quality rural nursing and medical services whichcan provide the health care necessary for rural communi-ties to grow and prosper.

The future holds a challenge for us all.

Vision for the future for rural nurses

My vision for the ideal advanced rural primary nurse ofthe future is of a highly trained generalist, multifacetedregistered nurse, educated at Masters level. She/he willhave acquired the appropriate clinical and theoreticalknowledge and skills for the speciality of rural primaryhealth care. This nurse will use research based evidenceto develop and provide the progressive, futuristic and,above all, appropriate health care service for rural com-munities. She/he will do this working in collaborationwith other members of the health care team (p. 38).15

Together let us embrace the challenge of the newhealth environment and strategically plan appropriate,accessible and affordable rural health care for the 21stcentury.

CONCLUSION

This paper has described rural primary healthcare nursingin New Zealand. Rural primary healthcare nurses havedemonstrated their leadership for the delivery of ruralhealth care. They have been challenged, both in theirclinical and academic practice while providing anextremely worthwhile health service to rural New Zealan-ders. The delivery of rural health services has been upagainst an array of difficult situations among whichinclude: lack of support, appropriate training and profes-sional development. Following a survey undertaken by theauthor, Rural Practice Nurse Skills Project, 19961 and withcontinued funding, an appropriate rural nurse clinicalcourse was developed. This process has been discussedwithin this paper. This course has led to the recognition ofrural nurses’ contribution to the sustainability of ruralhealth services. This paper challenges the recognition of

rural nurses’ contribution for the development of a collab-orative health practitioner and community model for thedelivery of future rural health services in New Zealand.

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