The delivery of Primary Health Care in remote Australian communities: A Grounded Theory study of the perspective of nurses

Around 85% of Australia’s landmass is remote and sparsely populated. Across these vast areas of desert, wilderness and tropical islands, nurses provide the majority of health care services. The residents of Australia’s remote communities have poorer health status than their metropolitan counterparts. The proportion of Indigenous people is high and health and social disadvantage is widespread. The characteristics of each remote community are unique and often reflect challenges associated with distance to tertiary health services and limited health resources. As a result, nursing practice within this context is very different to other nursing contexts. Despite recognition of Primary Health Care (PHC) as a comprehensive model of acute and preventative care well suited to areas of high health and social need, there is little known about how nurses use the PHC model in practice and research pertaining to this nursing context is limited. This study was conducted from a Constructivist Grounded Theory perspective to generate a substantive theory. Data were collected through 23 telephone interviews and an expert reference group. This study adds previously unknown information to the body of work about remote area nursing. The context of providing PHC in a remote setting was described as social with a focus on illness prevention and equality of care. Participants described personal satisfaction as a feeling of making a difference to the health and wellbeing of the community. However, the core issue participants faced was the inability to provide PHC. Four conditions that impacted on the core issue, were described as: understanding of the social world of the remote community, availability of resources, clinical knowledge and skill and, shared understanding and support. The process labelled doing the best you can with what you have emerged as the way participants dealt with the inability to provide PHC. The process involved four primary activities: facilitating access to health care, continually learning, seeking understanding, and home‐making in a work environment. The outcome of this process was considered to be making compromises to provide PHC. This study proposes a substantive theory to understand and explain Australian remote nursing practice. Recommendations include further exploration, testing and refinement of the substantive theory. The implications for practice include development of education and support programs and the findings promote the case for providing additional resources to health services in remote areas in order to support nurses in providing PHC

The delivery of Primary Health Care in remote Australian communities: A Grounded Theory study of the perspective of nurses

Around 85% of Australia’s landmass is remote and sparsely populated. Across these vast areas of desert, wilderness and tropical islands, nurses provide the majority of health care services. The residents of Australia’s remote communities have poorer health status than their metropolitan counterparts. The proportion of Indigenous people is high and health and social disadvantage is widespread. The characteristics of each remote community are unique and often reflect challenges associated with distance to tertiary health services and limited health resources. As a result, nursing practice within this context is very different to other nursing contexts. Despite recognition of Primary Health Care (PHC) as a comprehensive model of acute and preventative care well suited to areas of high health and social need, there is little known about how nurses use the PHC model in practice and research pertaining to this nursing context is limited. This study was conducted from a Constructivist Grounded Theory perspective to generate a substantive theory. Data were collected through 23 telephone interviews and an expert reference group. This study adds previously unknown information to the body of work about remote area nursing. The context of providing PHC in a remote setting was described as social with a focus on illness prevention and equality of care. Participants described personal satisfaction as a feeling of making a difference to the health and wellbeing of the community. However, the core issue participants faced was the inability to provide PHC. Four conditions that impacted on the core issue, were described as: understanding of the social world of the remote community, availability of resources, clinical knowledge and skill and, shared understanding and support. The process labelled doing the best you can with what you have emerged as the way participants dealt with the inability to provide PHC. The process involved four primary activities: facilitating access to health care, continually learning, seeking understanding, and home‐making in a work environment. The outcome of this process was considered to be making compromises to provide PHC. This study proposes a substantive theory to understand and explain Australian remote nursing practice. Recommendations include further exploration, testing and refinement of the substantive theory. The implications for practice include development of education and support programs and the findings promote the case for providing additional resources to health services in remote areas in order to support nurses in providing PHC

Violence towards remote area nurses: A Delphi study to develop a risk management approach

Incidents of occupational violence against nurses are unacceptably high. Remote AreaNurses in Australia frequently encounter violence in the work place and have limitedresources to deal with the problem. Adopting a risk management approach, andutilising the Delphi method, a panel of expert Remote Area Nurses (n=10) fromgeographically diverse communities, identified and prioritised hazards that increase therisk of violence and made suggestions for controlling those hazards.Priority hazards included; building maintenance and design, attending call-outs awayfrom the clinic, staff inexperience and lack of knowledge about the community, as wellas intoxicated clients, communication difficulties and a work culture that accepts verbalabuse as “part of the job”. Orientation, education and support of staff were identified asstrategies to improve the personal safety of Remote Area Nurses, along with staffinvolvement in the development of policies and procedures. Collaboration between thecommunity and health service to address the broader issues of violence within thecommunity and towards health service staff was identified as an essential strategy inreducing the risk of violence. A toolbox‟ of strategies is suggested in recognition of the complex nature ofoccupational violence within the remote health context. Further development andassessment of these tools could decrease the incidence of violence amongst remotehealth professionals in Australia and overseas

Voices from the bush: remote area nurses prioritise hazards that contribute to violence in their workplace

Introduction: Remote Area Nurses (RANs) in Australia frequently encounter hazards that contribute to violence in the work place. Resources to deal with this problem are limited. Methods: Adopting a risk management approach and using the Delphi method, a panel of expert RANs (n=10) from geographically diverse communities across Australia, identified and prioritised hazards that increase the risk of violence to nurses. Results: This descriptive study found that RANs encounter a wide variety of hazards from a variety of sources. Environmental hazards are complicated by living in remote areas and practicing in different locations. Relationships between the nurse and the community can be complex and lack of experience and organisational support may contribute to an increased risk of violence. Hazards prioritised as \u27major\u27 or \u27extreme\u27 risks included: clinic maintenance and security features, attending to patients at staff residences, RAN inexperience and lack of knowledge about the community, as well as intoxicated clients with mental health issues. A work culture that accepts verbal abuse as \u27part of the job\u27 was identified as a significant organisational risk to RANs. A lack of action from management when hazards are identified by clinic staff and insufficient recognition of the risk of violence by employers were also significant hazards. Conclusions: Further consideration of the hazards described in this study following the risk management process, may provide opportunities to reduce the risk of violence towards RANs. Proposed control measures should be developed in consultation with RANs and the remote communities they work in

Models of clinical supervision of relevance to remote area nursing & primary health care: A scoping review

Introduction: Nurses in remote primary health care settings work in difficult conditions, in isolated and disadvantaged communities, and often must work beyond their scope to provide advanced assessments and treatments to support the community. Therefore, remote area nurses require support to develop their skills and knowledge to work safely within their full scope of practice. Clinical supervision is widely used in health professions for this purpose; however, models of supervision for nursing have not been implemented or evaluated within remote primary health care settings. Objective: The purpose of this study was to search the literature to source suitable clinical supervision models that could pertain to the remote area nursing context. Design: An initial search of the literature found no clinical supervision models developed for remote or isolated practice nurses so a scoping review was conducted searching for publications related to advanced practice generalist health practitioners in primary health care, including practice nurses, nurse practitioners and general practitioners. This was seen as a suitable substitute because the phenomena of interest were the model of supervision rather than the specific skills or knowledge being developed. Findings: The scoping review search yielded 251 articles from 5 journal databases of which 11 articles met the inclusion criteria. Each clinical supervision model was described and synthesised using qualitative description. The 11 models of clinical supervision had differing formats including; individual and group clinical supervision, in-person, telephone, medical records review and video case study. Discussion: Whilst several models were described in the literature, none were directly transferrable to the remote area context. The absence of supervision for cultural safety was significant. There was a variety of modes including face-to-face, virtual, individual and group proposed. Cultural considerations were lacking in all of the models. Conclusion: Our study recommends a hybrid clinical supervision model suitable for consultation and validation through pilot testing with remote area nurses. There is potential for this model to be used globally in isolated contexts due to the option of virtual participation

Physiological plateaus during normal labor and birth: A novel definition

Background: Diagnoses of labor dystocia, and subsequent labor augmentation, make one of the biggest contributions to childbirth medicalization, which remains a key challenge in contemporary maternity care. However, labor dystocia is poorly defined, and the antithetical concept of physiological plateaus remains insufficiently explored. Aim: To generate a definition of physiological plateaus as a basis for further research. Methods: This qualitative study applied grounded theory methods and comprised interviews with 20 midwives across Australia, conducted between September 2020 and February 2022. Data were coded in a three-phase approach, starting with inductive line-by-line coding, which generated themes and subthemes, and finally, through axial coding. Results: Physiological plateaus represent a temporary slowing of one or multiple labor processes and appear to be common during childbirth. They are reported throughout the entire continuum of labor, typically lasting between a few minutes to several hours. Their etiology/function appears to be a self-regulatory mechanism of the mother-infant dyad. Physiological plateaus typically self-resolve and are followed by a self-resumption of labor. Women with physiological plateaus during labor appear to experience positive birth outcomes. Discussion: Despite appearing to be common, physiological plateaus are insufficiently recognized in contemporary childbirth discourse. Consequently, there seems to be a significant risk of misinterpretation of physiological plateaus as labor dystocia. While findings are limited by the qualitative design and require validation through further quantitative research, the proposed novel definition provides an important starting point for further investigation. Conclusion: A better understanding of physiological plateaus holds the potential for a de-medicalization of childbirth through preventing unjustified labor augmentation

Consumer perspectives of quality care: Exploring patient journeys from remote primary healthcare clinics to Alice Springs hospital

Problem or background: Residents of Australia\u27s remote regions have lower life expectancies and poorer health outcomes than other Australians. Access to hospital and specialist care frequently requires transport via road or air and time spent away from family and community. Question, hypothesis or aim: To explore consumer perspectives of the journey from remote communities to regional health services and identify areas for improvement. Methods: Individual interviews (n = 16) and yarning circles were used to collect and interpret stories of patient\u27s journeys. Findings: Travel for medical care was common and often required multiple journeys. Complex social and financial barriers to accessing care included costs associated with travel, food, and accommodation for patients and their families, a lack of understanding of the process and requirements of retrieval, difficulty arranging own road transport, and lack of availability of services within the community. These barriers extend to difficulties in attending follow-up outpatient appointments and return to the community after a journey to the hospital. Discussion: Educational resources may also be used to describe the retrieval process to remote community members to demystify acute health care in Central Australia but also to express the health service commitment to quality improvement through consumer voice. These resources may be used to orientate new health service employees to patient experiences and perspectives so that these can be incorporated into care planning to enhance cross-cultural understanding. Conclusion: Travel to access healthcare is an essential component of health services for remote communities. Targeted education for residents on travel expectations and education for staff may significantly reduce barriers to healthcare access

Nursing in a different world: Remote area nursing as a specialist–generalist practice area

Objective Remote area nurses provide primary health care services to isolated communities across Australia. They manage acute health issues, chronic illness, health promotion and emergency responses. This article discusses why their generalist scope of practice should be formally recognised as a specialist nursing practice area. Design Constructivist grounded theory, using telephone interviews (n = 24) with registered nurses and nurse practitioners. Setting Primary health care clinics, in communities of 150–1500 residents across Australia. Participants A total of 24 nurses participated in this study. Results Nurses\u27 perceived their clinical knowledge and skill as insufficient for the advanced, generalist, scope of practice in the remote context, especially when working alone. Experience in other settings was inadequate preparation for working in remote areas. Knowledge and skill developed on the job, with formal learning, such as nurse practitioner studies, extending the individual nurse\u27s scope of practice to meet the expectations of the role, including health promotion. Conclusion Remote area nursing requires different knowledge and skills from those found in any other nursing practice setting. This study supports the claim that remote area nursing is a specialist–generalist role and presents a compelling case for further examination of the generalist education and support needs of these nurses. Combined with multidisciplinary collaboration, developing clinical knowledge and skill across the primary health care spectrum increased the availability of health resources and subsequently improved access to care for remote communities. Further research is required to articulate the contemporary scope of practice of remote area nurses to differentiate their role from that of nurse practitioners

Failure to progress or just normal? A constructivist grounded theory of physiological plateaus during childbirth

Background and problem: During childbirth, one of the most common diagnoses of pathology is ‘failure to progress’, frequently resulting in labour augmentation and intervention cascades. However, failure to progress is poorly defined and evidence suggests that some instances of slowing, stalling and pausing labour patterns may represent physiological plateaus. Aim: To explore how midwives conceptualise physiological plateaus and the significance such plateaus may have for women\u27s labour trajectory and birth outcome. Methods: Twenty midwives across Australia participated in semi-structured interviews between September 2020 and February 2022. Constructivist grounded theory methodology was applied to analyse data, including multi-phasic coding and application of constant comparative methods, resulting in a novel theory of physiological plateaus that is firmly supported by participant data. Findings: This study found that the conceptualisation of plateauing labour depends largely on health professionals’ philosophical assumptions around childbirth. While the Medical Dominant Paradigm frames plateaus as invariably pathological, the Holistic Midwifery Paradigm acknowledges plateaus as a common and valuable element of labour that serves a self-regulatory purpose and results in good birth outcomes for mother and baby. Discussion: Contemporary medicalised approaches in maternity care, which are based on an expectation of continuous labour progress, appear to carry a risk for a misinterpretation of physiological plateaus as pathological. Conclusion: This study challenges the widespread bio-medical conceptualisation of plateauing labour as failure to progress, encourages a renegotiation of what can be considered healthy and normal during childbirth, and provides a stimulus to acknowledge the significance of childbirth philosophy for maternity care practice

Are remote health clinics primary health care focused? Validation of the primary health care engagement (PHCE) scale for the Australian remote primary health care setting

AIM: To test and validate a measure of primary health care (PHC) engagement in the Australian remote health context. BACKGROUND: PHC principles include quality improvement, community participation and orientation of health care, patient-centred continuity of care, accessibility, and interdisciplinary collaboration. Measuring the alignment of services with the principles of PHC provides a method of evaluating the quality of care in community settings. METHODS: A two-stage design of initial content and face validity evaluation by a panel of experts and then pilot-testing the instrument via survey methods was conducted. Twelve experts from clinical, education, management and research roles within the remote health setting evaluated each item in the original instrument. Panel members evaluated the representativeness and clarity of each item for face and content validity. Qualitative responses were also collected and included suggestions for changes to item wording. The modified tool was pilot-tested with 47 remote area nurses. Internal consistency reliability of the Australian Primary Health Care Engagement scale was evaluated using Cronbach\u27s alpha. Construct validity of the Australian scale was evaluated using exploratory factor analysis and principal component analysis. FINDINGS: Modifications to suit the Australian context were made to 8 of the 28 original items. This modified instrument was pilot-tested with 47 complete responses. Overall, the scale showed high internal consistency reliability. The subscale constructs \u27Quality improvement\u27, \u27Accessibility-availability\u27 and \u27population orientation\u27 showed low levels of internal consistency reliability. However, the mean inter-item correlation was 0.31, 0.26 and 0.31, respectively, which are in the recommended range of 0.15 to 0.50 and indicate that the items are correlated and are measuring the same construct. The Australian PHCE scale is recommended as a tool for the evaluation of health services. Further testing on a larger sample may provide clarity over some items which may be open to interpretation