International Journal of Nursing Practice 2000; 6: 283

Over recent years, as fiscal pressures on Governments have increased and the push for hospital productivity hasgrown, there has been increasing pressure for smallerrural hospitals to change their service-delivery role or beclosed down. More often than not, the central activitiesof rural hospitals in most countries are in-patient nursingservices for older people, domicilliary care, communityhealth and health promotion activities and, in some cases,a range of primary-health and casualty-care services supported by general practitioners. Rural people gener-ally have limited access to specialist medical services andallied health services, such as physiotherapy and occupa-tional therapy

In countries with a large land mass and scattered, smallpopulations (such as Canada,Australia and parts of Africa),nurses provide most of the health-care services to allmembers of the community; whereas, rural dwellers inmore densely populated countries (such as parts of theUnited Kingdom and the small island populations) haveonly a few miles to travel to access the whole gamut ofmodern health-service professionals. Not surprisingly,rural people who are far away from medical specialists areincreasingly dissatisfied with the nurse-led services thathave served them so well for so long, because of therelentless specialization of health care in the large urbancentres.

The development of telemedicine or e-health (that is, the ability to access specialists from remote sites via telecommunication) may to some extent alleviate this growing discomfort felt by rural people. More im-portantly, the enthusiasm felt within nursing about thedesirability and effectiveness of the nurse practitioner

needs to be more effectively promoted to the general pop-ulation. Even though a large number of studies show thatpeople who are cared for by nurse practitioners are as satisfied with their care as those cared for by medical practitioners, this does not seem to be the case with ruralpopulations.

Most of us share the view that the medical practitioneris the very best person to diagnose and treat illness, andthe nurse is the best person to assist individuals and com-munities to meet their own care needs; and therein liesthe basis of the rural health service dilemma. If themedical practitioner is the best person, then the nursepractitioner must be the second best! And if a nurse is notjudged to be sufficiently competent to deliver specificinterventions in the city, but able to do so in the rural hin-terland, doesn’t that suggest that city dwellers are moreworthy of ‘experts’ that the rural dweller? As the role ofthe nurse practitioner/advanced-practice nurse, howeverstyled, continues to occupy the minds of health planners,nurses and doctors when they consider meeting the healthneeds of rural people, it may be time for all concerned toreview the roles of health professionals in a ‘whole-of-health-service’ context and to cease this illogical cate-gorisation of ‘proper’ nursing work and medical workaccording to the distance between the city centre and thecommunity.

There are no quick, easy solutions to our very muddledthinking in this area; but there are pressing reasons for usto be a little more consistent in our arguments.

Alan PearsonEditor

✠ E D I T O R I A L ✠

Nurses, doctors and rural health care