Educating for rural nursing practice

ISSUES AND INNOVATIONS IN NURSING EDUCATION

Educating for rural nursing practice

Amanda Kenny BN MN RN

Lecturer in Nursing, LaTrobe University Bendigo, Bendigo, Victoria, Australia

and Stephen Duckett PhD

Professor of Health Policy, LaTrobe University, Victoria, Australia

Submitted for publication 11 November 2002

Accepted for publication 23 June 2003

Correspondence:

Amanda Kenny,

Lecturer in Nursing,

LaTrobe University Bendigo,

PO Box 199,

Bendigo,

Victoria,

Australia.

E-mail: [email protected]

KENNY A. & DUCKETT S. (2003)KENNY A. & DUCKETT S. (2003) Journal of Advanced Nursing 44(6), 613–622

Educating for rural nursing practice

Background. Rural hospitals in Australia, as in many countries, face challenges in

ensuring that appropriate, quality services are provided.

Aims. The overall aim of this study was to explore the issues that impact on the

ability of rural hospitals to provide effective health care.

Methods. We used a qualitative descriptive method and purposive sampling, and

conducted interviews in hospitals in rural Victoria, Australia. The data collected

enabled major issues that impact on hospital service delivery to be identified. Using

thematic analysis, global themes were extracted and organized around a thematic

network.

Findings. The workforce was an important theme. Whilst the impact of medical

shortages on hospital function has been considered in other studies, little considera-

tion has been given to the rural nursing workforce. The need to maintain an appro-

priately educated rural nursing workforce emerged as one of the major issues that

impact on rural hospital service delivery. In Australia, there has been a great deal of

discussion about the educational preparation required for rural nursing practice, with

the emphasis on postgraduate study. However, the majority of rural nurses do not

have postgraduate qualifications and face significant barriers in obtaining them.

Although the vast majority of literature claims that postgraduate preparation is vital

for rural nursing practice, this research suggests that the future rural nursing work-

force will be recruited from undergraduate courses in regional universities. However,

there is a need to include specific theoretical and operational preparation in under-

graduate education, to enable nurses to make the transition to rural practice more

readily.

Conclusions. Rural nurses are central to the delivery of health services in rural hos-

pitals. Future rural nursing recruitment and retention hinges on ensuring that they

have the confidence, knowledge and skills to deliver safe, appropriate and effective care.

Keywords: nursing, rural nursing, hospitals, education, recruitment, retention

Introduction

The viability of rural health care services is directly related to

the maintenance of a stable, efficient and well-educated

workforce. Australia, like many countries, is facing enormous

challenges in providing health care in rural areas. The ability

of rural hospitals to maintain a high standard of service is

threatened by major workforce recruitment and retention

difficulties.

� 2003 Blackwell Publishing Ltd 613

Literature review

After years of benign neglect (Humphreys 1999, Janes 1999),

rural health in Australia is gaining an increased profile. Major

reports have indicated significant differences between the

health status of rural and metropolitan residents. Overall age-

standardized death rates are higher in rural areas than

metropolitan. In particular, death rates and hospitalization

from injury are significantly higher in rural areas. Higher

percentages of rural residents are hospitalized for diabetes,

stroke, and heart and vascular disease and there are serious

concerns about higher levels of mental health problems and

suicide (Australian Institute of Health and Welfare 1998,

2002).

Australia is faced with crucial shortages of medical

practitioners in rural areas (Alexander 1998, Strasser et al.

2000, Humphreys et al. 2002) and small rural hospitals

struggle to maintain adequate services (Duckett & Kenny

2000). Similar issues that threaten the sustainability of rural

hospitals, such as workforce shortages, financial difficulties,

increased need for capital, competition for market share and

the impact of the shift from inpatient to outpatient care on

hospital function, have been identified internationally

(Moscovice & Rosenblatt 2000, Ricketts 2000, Trinh &

O’Connor 2000, Basu & Friedman 2001).

Interestingly, in spite of the fact that nurses play a major

role in health care delivery and comprise approximately

60% of the entire health workforce in Australia (Duckett

2000), only cursory consideration has been given to the

role that rural nurses play in hospital service delivery

(Francis et al. 2001). In Australia, medicine has tradition-

ally dominated the division of labour in the health sector

‘economically, politically, socially and intellectually’ (Willis

1993, p. 2), and there is little indication that this dominance is

waning. Germov (2002) contends that medicine’s alignment

with conservative politics has supported its power struc-

tures. It could be argued that this power is the reason why

issues surrounding medical recruitment and retention have

monopolized the attention of government and health policy

makers and have squeezed consideration of the issues

impacting on the nursing workforce off the political

agenda.

Australia is currently facing acute nursing shortages

(Senate Community Affairs Committee 2002). In rural areas,

it is claimed that nursing workforce problems will ‘dwarf

the lack of doctors in the bush’ (Best 2000, p. 93). The low

priority that has been given to rural nursing over recent

years and the ‘lack of an integrated, cohesive strategy for

dealing with nursing workforce issues affecting remote and

rural Australia’ (Senate Community Affairs Committee

2002, p. 169) are producing an imminent critical work-

force shortage, which will impact directly on service

delivery.

The inability of international policymakers to provide an

agreed, standard definition of what constitutes ‘rural’

(Addington et al. 1995, Verheij 1996, Humphreys 1998,

Christianson et al. 2000) makes the task of defining rural

nursing difficult. In Australia, the definitions that have been

proposed often conflate a geographical component with

service characteristics (Kreger 1991, Thornton 1992, Hegney

et al. 1999). These definitions, however, fail to describe the

diversity of rural locations and the heterogeneity of nursing

practice adequately. Although it is impossible to provide a

succinct definition of rural nursing that encompasses the

diversity of geographic locations, the varied nature of the

rural nursing role has been reported internationally (Bushy

1998, Handley & Blue 1998, Anderson-Loftin 1999, Hegney

& McCarthy 2000, Krothe et al. 2000, Offredy 2000, Bushy

2001, Francis et al. 2001, Hegney et al. 2002, MacPhee &

Scott 2002).

The diversity of services provided by rural hospitals

(Shreffler 1996, Drummond 1998, Hutten-Czapski 1998,

Rourke 1998, Sariego 1999) means that rural nurses need to

be multi-skilled generalists who are often faced with making

decisions in the absence of other health professionals (Hegney

& McCarthy 2000). In Australia, the major difficulties that

rural areas have in attracting medical practitioners are well

documented (Strasser et al. 2000, Humphreys et al. 2002).

Most rural hospitals lack on-site medical staff, and much of

the literature focuses on rural nurses taking on advanced and

extended practice roles such as radiography, medication

prescribing, advanced assessment, and management of

trauma and emergencies because of the absence of other

health professionals (Robbins 1994, Hegney et al. 1997a,

Keyzer 1997, Hegney 1998, Ross 1999, Hegney & McCarthy

2000).

Although, in Australia, rural health services have tradi-

tionally experienced low turnover and a relatively stable

nursing workforce (Hegney & McCarthy 2000), the impact

of overall nursing shortages is having a major effect on rural

areas. Current workforce difficulties will be exacerbated by

the ageing of the rural nursing workforce (Strong et al. 1998,

Hegney & McCarthy 2000, Francis et al. 2001). Some

studies suggest that 50% of the existing rural nursing

workforce is older than 40 years of age (Hegney &

McCarthy 2000). It has also been suggested that this figure

is closer to 80% in some locations, and that the majority of

rural nurses are over 50 years old (Francis et al. 2001).

Difficulties with recruitment and retention and an ageing

rural nursing workforce are not confined to Australia and

A. Kenny and S. Duckett

614 � 2003 Blackwell Publishing Ltd, Journal of Advanced Nursing, 44(6), 613–622

have been reported internationally (Fuszard et al. 1990,

LaSala 1995, Bushy 2000).

The diversity of rural practice and the complexity of the

rural nursing role require nurses to have a strong theoretical

and practical knowledge base. In much of the literature there

is an emphasis on postgraduate education (Hegney 1996,

Long et al. 1997). Because of the diversity of rural practice

and the often advanced role that nurses must undertake, it

has been argued that specific postgraduate education be

undertaken prior to rural practice (Mardros 1993). Increas-

ingly, the nurse practitioner role is suggested as being

particularly relevant to the rural context (Australian Health

Ministers’ Conference 1994, Krein 1997, Hegney 1998,

Nurse Practitioner Taskforce 2000, Heath et al. 2002).

Internationally, nurse practitioners are prepared at master’s

level (Roberts 1996, Ross 1999), and there are indications

that the same level of educational preparation will be adopted

in Australia (Heath et al. 2002).

In spite of the emphasis on advanced educational prepar-

ation for rural practice, the majority of nurses working in

these areas do not have postgraduate qualifications and face

enormous difficulties in pursuing postgraduate study. A

number of authors argue that it is not possible to prepare

nurses at undergraduate level for rural practice (Kreger 1991,

McDonald 1994, Reid 1994, Bell et al. 1995, Huntley 1995,

Hegney et al. 1997b). However, there may be a need to

recruit more and younger nurses to rural areas to ensure the

viability of local health services (Hegney & McCarthy 2000).

Whilst the notion of advanced educational preparation is

ideal, in view of the complexities of rural environments and

the lack of medical support that is often evident, the reality is

that in many rural areas the future nursing workforce will be

recruited from undergraduate courses.

In Australia, Registered Nurses used to be hospital-trained

under an apprenticeship model. In 1984, the Commonwealth

Government announced the transfer of nurse education to the

tertiary education sector. Initially, the entry level of practice

was at undergraduate diploma level. In 1992, entry level was

upgraded from diploma to degree level (Francis &

Humphreys 1999). The transfer of nurse education from

the apprenticeship model to an academic model was

completed in 1994 (Heath et al. 2002).

The recent Australian senate inquiry into nursing (Senate

Community Affairs Committee 2002) was extremely critical

of universities and suggested that there has been a failure to

educate graduates adequately for rural practice. Whilst the

inquiry did not provide specific details of why this conclusion

was reached, it suggested that there is a need to improve the

structure of undergraduate programmes in order to prepare

students to practice in an environment that often requires

nurses to make decisions and manage clients without imme-

diate access to medical staff.

The study

Aim

The aim of this large qualitative descriptive study was to

explore the overall issues that impact on service delivery in

rural hospitals in Victoria, Australia.

Setting and sample

Victoria is Australia’s smallest mainland state and the second

most populous, with a population of 4Æ7 million. Metropol-

itan Melbourne has a population of 3Æ4 million, and the rest

of the population lives in regional Victoria (Australian

Bureau of Statistics 2002). Hospital services for Victoria’s

regional population are primarily provided by rural public

hospitals. Victoria’s 69 rural public hospitals are managed by

government appointed boards and monitored by the Depart-

ment of Human Services. For management purposes, regional

Victoria is divided into five regions. The hospitals chosen for

this study were taken from all five areas, and were deemed to

be broadly representative of all hospitals in the state in terms

of geographic and demographic characteristics. In Victoria,

hospitals are classified into size-related groups. Large metro-

politan teaching hospitals are categorized as A, and rural

hospitals fall into groups B to E, with group E representing

the very smallest hospitals. The sample of hospitals chosen

for this study represented every group.

Curtis et al. (2000) highlight the importance of sampling in

qualitative research. In our study, the use of purposive

sampling (Patton 1990) ensured that participants were key

informants and had the appropriate knowledge to provide

relevant and rich forms of data (Popay et al. 1998). The

sample size was large for a qualitative study (Sandelowski

1995), with 60 in-depth interviews conducted with hospital

managers, chief executive officers, nursing staff and rural

doctors.

Data collection

All the audiotaped interviews were conducted by one

researcher (AK). Participants were asked a broad question:

‘What are the critical issues that impact upon the delivery of

rural health services?’ They identified the rural workforce and

education for rural practice as major issues. Each participant

was encouraged to discuss these issues in detail and

interviews lasted approximately 1 hour.

Issues and innovations in nursing education Educating for rural nursing practice

� 2003 Blackwell Publishing Ltd, Journal of Advanced Nursing, 44(6), 613–622 615

Ethical considerations

Ethics approval for the study was obtained from a university

ethics committee. Each participant was provided with written

information about the study and informed consent was

sought. Participants were not asked to identify themselves on

tape during interviews. An assurance was given that any

information was confidential and that no statements would

be identified as being made by any particular participant.

Data analysis

An inductive approach was taken (Patton 1990), with data

collection and analysis conducted as an integrated process

(Ezzy 2002). Interviews were transcribed by the interviewer,

and this process provided an in-depth understanding of the

data and enabled the process of transcription to become part

of analysis. During transcription AK could consider the

findings in relation to the context from which they were

derived (Geertz 1973), the rural hospital. The study yielded a

vast amount of data. A cyclical process of analysis was

utilized, which involved reading, rereading, assimilating,

interpreting and understanding (Rose & Webb 1998). Data

were coded for recurring regularities, and basic themes were

identified and clustered into organizing themes. The final

process involved the clustering of organizing themes into

global themes, using a thematic network as described by

Attride-Stirling (2001).

Findings and discussion

One of the major overall issues that impacted on service

delivery in rural hospitals was the workforce. This emerged as

one of the major global themes, and is the focus of this paper.

The diversity of rural practice

Although the 20 rural hospitals visited as part of this study

were diverse in terms of location, size, resources and services

provided, there were common characteristics, most notably a

lack of medical support and supervision for nurses. This

placed a great deal of pressure on rural nurses.

Our study indicated that nursing practice in rural hospitals

was diverse:

We get lots of sports injuries. We have as many as 300 kids playing

football here of a weekend. People fall off horses, motorbikes, farm

accidents, they all present at the hospital. Then, on top of all of that,

we run a surgical list and have a full mix of medical and surgical

inpatients. We had an accident last week where they bought the

person in to be stabilized, even though they were going to be airlifted.

It was better to bring them here than manage on the road. (Chief

Executive Officer, Group B hospital)

The varied nature of rural nursing practice has been identified

in a number of countries (Fuszard 1991, Clark et al. 1996,

Bushy 1998, Handley & Blue 1998, MacLeod et al. 1998,

Hegney & McCarthy 2000, Witham 2000, Bushy 2001,

Francis et al. 2001, MacPhee & Scott 2002). The challenge is

to ensure that rural nurses have the knowledge and skills to

manage the diversity of their role effectively. In our study, the

majority of nurses were trained to hospital certificate level

and did not have any formal university qualifications. A

nursing director noted:

Our nurses are getting older. Most of them were trained in hospitals a

long time ago. They have years of experience but very few of the staff

have done any university study. (Director of Nursing, Group E

hospital)

The lack of university education amongst rural nurses has

been reported in other studies, although there has been no

research that has quantified exact numbers (Handley & Blue

1998, National Rural Health Alliance 2001). Rural areas are

characterized by an ageing nursing workforce (Strong et al.

1998, McCarthy et al. 2000, Francis et al. 2001) and our

study suggests that most rural nurses have trained under the

apprenticeship model.

Hospitals reported difficulty in releasing staff to upgrade

and update skills:

We know that they need better education but it is really hard. If

we let them go we can’t replace them. Who is going to staff the

wards? We are short already. (Chief Executive Officer, Group D

hospital)

Registered Nurses discussed personal factors that impacted

upon their ability to pursue education. Factors such as cost,

family commitments, lack of interest, approaching retirement

and fear of tertiary education were identified:

You have to realise that most of our staff were trained in hospitals.

To then turn around and go to university to study involves a lot of

stress. Most of them have families. The closest university is three

hours away. (Director of Nursing, Group C hospital)

Barriers to postgraduate study have been identified else-

where (Kreger 1991, Hegney et al. 1997b). Difficulties with

release for education, the proportion of nurses whose

highest qualification is at hospital certificate level, and the

age of the rural nursing workforce were highlighted in the

recent Australian nursing senate inquiry (Senate Community

Affairs Committee 2002). Whilst there may be strategies



that could be implemented to improve access to postgradu-

ate study, discussion of this issue is beyond the scope of our

article. The obstacles that rural nurses face to pursue

postgraduate study raise doubts about suggestions that

nurse practitioners may be a solution to some of the

challenges facing rural areas (Nurse Practitioner Taskforce

2000). Participants identified a role for the nurse practi-

tioner, but administrators were pragmatic about the likeli-

hood of gaining the services of these advanced, extensively

experienced practitioners:

There is definitely work for a nurse practitioner. To have someone

with those sorts of skills would be fantastic but, really, we can’t get

any nurses. At the moment anyone would do. (Director of Nursing,

Group B hospital)

Although studies have supported the view that nurse prac-

titioners provide high quality services in a range of settings

(Brown & Grimes 1995, Grahame & West 1996, Sakr et al.

1999, Lee et al. 2000), it is unlikely that the nurse

practitioner role will be embraced on a widespread basis.

Although nursing administrators indicated that the potential

for nurse practitioners was limitless, there were suggestions

that opposition existed within medical ranks:

We have to be really careful here. The doctors are very precious

about their turf. (Director of Nursing, Group D hospital)

In countries where the nurse practitioner role is legitimized,

demand for services outstrips supply. Nurse practitioners are

predominately located in high volume hospitals with a full

complement of medical staff (Kassirer 1994, Robbins 1994,

Krein 1997). In rural Victoria, there are major difficulties in

attracting any nurses. Nurses with master’s level preparation

and advanced clinical experience would be as eagerly sought

as medical staff.

There is little doubt that, ideally, rural nurses should be

prepared at postgraduate level. However, staff in the hospi-

tals visited for this study viewed graduates from undergra-

duate courses as their future workforce:

We are all getting older. We need to recruit grads., young and

enthusiastic nurses who are beginning their careers. They will be our

future. (Director of Nursing, Group E hospital)

Strengthening undergraduate education

Although there is a perception that undergraduate prepar-

ation is inadequate for rural nursing practice (Kreger 1991,

McDonald 1994, Reid 1994, Bell et al. 1995, Huntley 1995,

Hegney et al. 1997b), the reality is that Victoria’s rural

hospital workforce is recruited primarily from undergraduate

degree courses conducted by regional universities.

Mardros’ (1993) suggestion that all nurses must have

specific preparation prior to rural practice is ideal, but

impractical in the vast majority of cases. In an ideal situation,

postgraduate studies, directed at providing advanced nursing

knowledge and skills, might enable nurses who are commen-

cing rural practice to be better equipped for the diversity of

situations that they will encounter. However, the more likely

scenario is that graduate nurses will learn their ‘jack of all

trades’ role on the job:

We have things happening here all the time. They [graduate nurses]

learn really quickly. (Director of Nursing, Group D hospital)

Our study suggested that there are marked differences

between rural and metropolitan nursing practice:

Nurses run the hospital. They take on so much responsibility. In the

city they have lots of staff around, doctors all the time. Here the

doctor may be an hour away. You are on your own. There is no one

down the corridor to call for help. (Director of Nursing, Group D

hospital)

The vast majority of nurses in Australia are now educated in

metropolitan universities and nurse education has focused on

preparing graduates to practice in metropolitan health care

settings (Bell et al. 1997, Hegney 1998). Major government

reports have criticized the lack of preparation for rural

practice in undergraduate courses, claiming that there is

‘considerable room for improvement’ and that universities

are ‘failing to provide staff with the confidence that they need

to work with minimal supervision’ (Senate Community

Affairs Committee 2002, p. 171).

Recommendations for undergraduate preparation

Although Hegney (1996) argues that the knowledge and skill

required to fulfil the extended practice role safely in rural

areas is not included in undergraduate education, this does

not preclude undergraduate courses from consciously inclu-

ding specific theoretical material that will enable graduates to

make the transition to rural practice more effectively. In

particular, our study identified management, mental health,

advanced health assessment and advanced life support as

areas of particular need. Advanced knowledge and skills in

these areas should be included in undergraduate courses,

particularly in rural universities.

Management and leadership

Although Crisp and Taylor (2001) suggest that new gradu-

ates are not faced with having to fulfil management and

leadership roles, this is a ‘metrocentric’ view. In many of the

smaller rural hospitals visited, there were only one or two



registered nurses on duty at any time. Often the nurse in

charge was newly graduated:

We have got great grads. They need to be. In a place like this they

take on a lot. It’s not like being in a large hospital with lots of staff.

On evening, there will often be a grad. and a couple of div. 2’s

[enrolled nurses]). (Director of Nursing, Group C hospital)

Inexperienced nurses were engaged in all facets of manage-

ment: planning, organizing, staffing, directing, coordinating,

reporting and budgeting. The environment of the rural

hospital often demanded that new graduates were faced with

the complex task of balancing leadership and management.

Management was often neglected in undergraduate pro-

grammes, but for graduates beginning rural practice, foun-

dational knowledge and practical skill are imperative. Nurses

employed in these hospitals often felt ill-prepared for

challenging management issues:

I am really confident on the wards but the politics [are] another story.

(Rural nurse, Group D hospital)

Mental health

There was no expectation that advanced mental health skills

could be taught within the constraints of an undergraduate

course. However, multiskilled generalists in rural areas

require foundational mental health knowledge, with adequate

mental health assessment skills and a broad understanding of

services for appropriate referral:

The mental health work is increasing. We quite regularly see mental

health clients. Security is another issue. I think it is a combination of

factors. The closures of inpatient services [is one factor]. We lost

inpatient beds and now there is only one 16-bed unit at the base

hospital that covers the whole region and that is it. We are getting

people who are severely depressed or schizophrenic or suicidal. They

turn up here and we have to try and cope with them. (Rural doctor,

Group D hospital)

Prior to the mid-1980s, Victoria’s mental health nurses were

prepared through a 3-year specialist direct-entry certificate.

With the demise of this course, mental health was integrated

into a comprehensive general nursing degree. However, there

are some who argue that the plan for a truly comprehen-

sive course has not been realized (Clinton & Hazelton

2000, Wynaden et al. 2000, Mullen & Murray 2002).

Rather, in most comprehensive courses, it is difficult to

identify the mental health component clearly. The demise

of mental health elements in comprehensive programmes

has been reported in other countries (Clinton et al. 2001,

Prebble 2001). In order to prepare adequately for rural

nursing, it is imperative that undergraduate students have

both theoretical preparation and clinical exposure to

mental health services. There is a current severe shortage

of mental health nurses in cities; our study suggests that in

rural areas mental health nurses are almost non-existent:

They [clients with mental health conditions] turn up at A & E

[the accident and emergency department]. The docs. have nowhere

to refer them and then you can’t get them a bed. They are stuck

here in an inappropriate environment. The staff have no psychiatric

qualifications nursingwise. (Chief Executive Officer, Group C

hospital)

This lack of staff with mental health experience is worrying,

particularly in view of key government rural health reports

that suggest higher levels of compromised mental health in

rural areas (Australian Health Ministers’ Conference 1994,

National Rural Health Policy Forum and National Rural

Health Alliance 1999). It is unlikely that rural areas will

attract specialist mental health staff. There is an urgent need

to ensure that undergraduate students receive appropriate,

specific mental health education and adequate clinical

experience in specific mental health facilities, to provide a

basic level of understanding as a preparation for the demands

of rural practice.

Advanced life support

Surprisingly, the majority of the hospitals visited in this study

had no or very few staff that were educated in advanced

cardiac life support (ACLS):

Our aim is to try and get more of them skilled to defib[rillate]. The

theatre nurse can do it but when she is off we are really thin on

the ground. We just do CPR [cardiorespiratory resuscitation]until the

doctor gets here and hope for the best. I know it is not ideal. (Director

of Nursing, Group D hospital)

This is difficult to understand in rural hospitals, partic-

ularly where there is no on-site medical staff. It is argued

that ACLS is part of the contemporary nursing role

(Kenward et al. 2002) and is of particular importance in

rural areas (Jones & Cooke 1996). The value of early

defibrillation is well-documented (Spearpoint et al. 2000,

Marenco et al. 2001, Kenward et al. 2002, Koster 2002),

and studies in rural hospitals have indicated that ACLS

education significantly increases resuscitation efforts and

results in the likelihood of more positive outcomes (Camp

et al. 1997). These studies all advocate early intervention.

ACLS must be incorporated into undergraduate education,

and all graduates beginning rural practice should be

accredited to provide first line emergency management

safely.



Advanced assessment skills

Our study clearly demonstrated the importance of advanced

assessment skills. Commonly, nurses in these hospitals were

called upon to make clinical judgements:

We looked at the figures and we are seeing 800 people a year that

aren’t seen by a doctor. More and more the nursing staff are making

clinical decisions. There is a set protocol. The doctors want to see any

children, anybody with a potentially serious head injury and chest

pain that is cardiac related. The nurses have to decide when to call.

(Director of Nursing, Group B hospital)

If up to 40% of clients presenting at rural emergency

departments are not seen by a doctor, this suggests a very

different situation from that existing in metropolitan

settings. In metropolitan hospitals with a full complement

of medical staff, the level of assessment skill required is not

as great as that needed by a sole rural nurse with medical

support 1 hour away. Advanced health assessment must

become a feature in undergraduate courses, particularly in

rural universities.

Undergraduate education: key to workforce shortages

In rural Victoria shortages of nursing staff may be reaching

critical levels:

Whichever way you look at it we are dramatically understaffed. We

can’t get registered nurses. When we are successful, it is hard to keep

them. They come here with inadequate preparation and just don’t

cope. (Director of Nursing, Group C hospital)

It is estimated that Victoria currently has between 600 and

800 nursing vacancies (Department of Human Services

Victoria 2002), and estimates place future nursing shortages

at 12 500 (Victorian Government 2002). There are no data

that provide a clear understanding of rural nursing short-

ages. Our study suggests that the key to long term

recruitment and retention in rural areas is educating staff

to ensure that they are confident to manage the complexities

of rural practice:

We predominantly get our staff from regional universities. The better

educated they are, the better the service to our community and the

more likely they are to stay. If they understand what rural practice is

like, get a taste of it when they are studying, they come here with

their eyes wide open. (Director of Nursing, Group D hospital)

One of the most important steps in ensuring a stable nursing

workforce is to ensure that undergraduate education provides

this ‘eye opening’ to the realities of rural practice and

provides some of the key skills that will be needed to function

successfully in a rural environment.

Conclusion

Maintaining an adequately prepared rural nursing workforce

is an important issue in rural hospitals. Internationally, it has

been argued that policymakers do not acknowledge the

differences between health care delivery in rural and urban

areas. It could be argued that universities have also failed to

recognize differences in rural and urban nursing practice. The

data and discussion presented in this article make an

important contribution by highlighting some of the rural/

urban differences and the realities with which hospitals must

contend. Nurses in our study fulfilled an extremely diverse,

multiskilled role, but were often inadequately prepared for

this. Other authors have highlighted the diversity of rural

nursing practice, and the often advanced and extended roles

that nurses fulfil in the absence of other health professionals,

particularly doctors. The demand has been for postgraduate

education. Advanced, experienced nurse practitioners deliv-

ering care in the absence of rural doctors has been proposed

as almost a panacea for the major medical recruitment

difficulties that rural areas are facing. What is not acknow-

ledged is that this vision does not reflect reality. Rural

Victoria, like many rural areas, is characterized by an ageing

nursing workforce. The vast majority of nurses working in

Victorian rural hospitals are not university educated, and

there is no evidence to suggest that large numbers of them are

pursuing postgraduate study. Although barriers that may

preclude rural nurses from pursuing postgraduate study have

been identified consistently over a number of years, these

barriers have not disappeared and it is unlikely that anything

will change in the short term. Whilst nurse practitioners have

been identified by a number of studies as being able to

provide cost-effective quality care, it is likely that their

services will be as difficult to obtain as those of rural doctors.

In countries where the nurse practitioner role is established,

the trend is for these nurses to practice in large, well-equipped

centres supported by a full range of specialist medical staff.

The government focus on rural doctor shortages is often to

the detriment of long-term planning for rural nursing.

Victoria, like all Australian states, is faced with acute nursing

shortages and projections for the future are dire. The reality is

that the future rural nursing workforce will be recruited

predominantly from the undergraduate ranks of regional

universities. With the reliance that rural communities have on

the nursing workforce to maintain health services, there is an

urgent need to stop grasping at idealized notions of postgra-

duate nursing education for rural practice.

Universities, particularly those located in regional areas,

need to refocus to ensure that they are preparing graduates to

meet the needs of rural hospitals and the communities that



they serve. Our article provides recommendations for key

areas that should be considered in the design of undergradu-

ate curricula. These relate to management, mental health,

advanced health assessment and advanced life support.

Whilst the areas highlighted are not an exhaustive list of all

of the knowledge and skills needed for rural practice, our

research suggests that they are areas that should be priorit-

ized. The current metrocentric approach to nurse education

ensures that the needs of rural hospitals are not met. By

adequately preparing beginning nurses for the challenging

and diverse role that rural practice entails, there is far more

likelihood of recruiting and retaining staff in rural areas. If

the status quo is maintained the future for rural hospitals,

rural communities and rural nursing is bleak.

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What this paper adds

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Educating for rural nursing practice