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The tyranny of distance
Workforce shortages in rural and remote areas
Lynette Smith, Primary Times writer
Source: APNA Primary Times Summer 2024-5
Everyone should have access to comprehensive, high-quality and appropriate health care. However, people in rural and remote parts of Australia often miss out. On the surface, it looks like a normal workforce supply issue. In reality, it’s a complex problem. It’s also an opportunity, though, for nurses and nurse practitioners who want a rewarding career working to their full scope of practice.
Australians are city lovers. Seventy-two percent of the population lives in a major city and most of those who don’t are based in large regional centres.1 City living makes it easy to get what you need. Everything’s close: goods, services, education and training, jobs and workers, friends. You have options for where and how you live. Things cost less.
Outside the cities, it’s the opposite in every way. Getting what you need is harder – including health care. Compared to people living in major cities, rural and remote residents experience higher rates of hospitalisations, deaths, and injuries, and reduced access to primary health care services.1 In addition to this, poorer access to health care is compounded by other health risks that go with living outside large cities, including lower education and incomes, higher rates of unemployment, coercive gender norms, and social isolation. The result is that the ‘burden of disease … increases with increasing remoteness.’2
Lifting the burden of disease
How do we lift the burden of disease for people living in rural and remote Australia? One piece of research suggests that several enabling conditions need to be in place, including healthcare workers’ genuine understanding of their patients’ circumstances. Rural and remote communities need healthcare providers who have a sense of loyalty and solidarity with them. They need people who are invested in their community in an enduring way and who can have ongoing, face-to-face relationships with their patients.2 That’s not a fly-in-fly-out proposition. But how do we get them there?
As part of Strengthening Medicare, the Commonwealth Government recently reviewed the ‘levers’ it uses to address workforce shortages. These levers focus on supply and distribution, with classifications that trigger funding and legal mechanisms that encourage or require health professionals to work in places where there is need.3
In its response to this review, APNA highlighted the importance of nurses in rural and remote communities, pointing out that in more remote parts of the country, nurses are often the only practitioner there, coordinating medical, allied health and specialist services so people get the care they need.4
This is confirmed by Kerida Hodge (right), General Manager, Communications and Business Analytics, at Rural Health West. Kerida says there are currently 30 nurse practitioners working in rural and remote parts of Western Australia. All of them are highly valued by their communities and colleagues.
Nurse practitioner Kylie Straube runs the first – and so far only – nurse-practitioner-led practice in the Northern Territory. ‘We have skilled clinicians in mental health, hepatology, chronic disease, midwifery, and child and women's health,’ she says. ‘Government policies and funding need to support them to work to their full scope of practice.’
Fostering a rural and remote workforce
Alongside the distribution levers, APNA advocates for training and placements to steer more nurses into rural and remote locations.
‘We’re working to give trainees a chance to find out what it would be like to work as nurse in rural and remote areas,’ says Donna Gleisner, APNA’s General Manager, Career Pathways.
It was with APNA’s support that Elise Sims did her placement in Maningrida in the North Territory. That experience caused her to completely change her career plans, showing that ‘you cannot be what you cannot see,’ says Donna.
For a placement to be a good experience, ‘we need to educate the town and get them on board,’ Donna adds. Doing 800 hours in an unfamiliar place where you have to arrange and pay for accommodation, as well as travel, childcare and food is difficult enough. For some, particularly trainees from a culturally and linguistically diverse background, a rural or remote town can be a severe culture shock or worse as they encounter attitudes, sometimes racist, that they don’t see in the city.
APNA’s Teaching Towns concept is designed to get a whole town involved in the student placement experience, so that it can build a sustainable health workforce.5 The project aims to embed student placement programs within each town’s culture, with local councils and associations brought on board to provide logistical and social support. ‘Broken Hill has done this really well,’ says Donna, ‘with cheap, safe student accommodation and support for students placed there, whether nurses, medical, OT or physio.’
‘Growing your own’ is another way to improve workforce supply, says Kerida. Rural Health West encourages and supports young people to consider a career in primary health care and to return to the community that they know. But going to university in a major city often means people are forming relationships and putting down roots that make it difficult to return to the country, so we need to look at how we can provide training and education in situ in regional communities.
It’s not just about the training pipeline. Medicare reforms in discussion now are crucial in rural and remote parts of the country. Communities need multidisciplinary teams—including nurse-led teams—of doctors, nurses, Aboriginal health workers, and allied health professionals working flexibly to their full scope of practice. Better funding models will help create those teams, but they will also make a practice viable and sustainable in the long run, which is, in turn, key to retaining the workforce in rural and remote Australia.
‘What I would love to see is a funding model like the one used in Aboriginal health,’ says Donna, ‘one where funding is provided according to the services needed rather than scheduled items, so you can build the clinic around the needs of a community.’
Administrative impediments to nurses working to their full scope of practice need to be dismantled. Ending collaborative arrangements, for example, made a huge difference to Kylie Straube in her practice in Berry Springs, near Darwin. More needs to be done to make nurse-led practices like hers sustainable.
Enduring challenges
Training, funding models, distribution levers, a workforce of people working to their full scope of practice. Even if all this changes, it still won’t be easy to provide high-quality health care in remote locations. Kerida lists poor-quality housing, high costs of living, safety concerns, and fewer employment prospects for a spouse and education options for children.
APNA has also identified issues in ‘childcare, internet access and transport … compounded by climate extremes that make living and working in these areas extremely difficult.’6
That list of issues will ring a bell for anyone who pays attention to the social determinants of health and wellbeing. Australians in rural and remote parts of the country experience a distinctive range of social, economic and environmental conditions, all of which play a part in their poorer health outcomes.
Those same conditions make it difficult to recruit and retain a workforce that can help improve those outcomes. And, without good health services, a town is less liveable, which makes a difference to whether people move or stay in a rural or remote town.7 That’s a complex problem.
Leveling up
There’s no denying the issues but, as Kerida points out, working in rural and remote communities can be a rewarding and empowering experience. It means leveling up: ‘working at the top of your scope of practice, seeing a variety of presentations, and building strong relationships with patients and colleagues,’ she says. For a nurse or nurse practitioner, rural and remote work presents a broad range of opportunities that are not available in urban centres.
With 23 years of nursing experience in rural and remote parts of Queensland and the Northern Territory, Kylie agrees with Kerida. She says she wants to be in her community ‘from the womb to the tomb,’ for whatever care people need. ‘You’ve got to be a bit of a provocateur to do this work. It’s the only way to get change.’
A provocateur
Just under a year ago, after her daughter said to ‘stop banging on about fragmented care and do something about it,’ Kylie Straube set up Remote Territory Healthcare in the rural areas around Darwin. It was the first, and still only, nurse-practitioner-led clinic in the Northern Territory.
She and her staff look after 7,500 people in about five distinct communities, from newborns to those aged ‘100 plus.’ She sees young families and retirees, tradies, FIFO households, and a significant number of veterans of conflict in East Timor, the Solomon Islands, and the Middle East. During the dry season, from April to September, tourists come from the south for the fishing and to visit the beautiful Litchfield National Park.
That means a wide variety of presentations at the clinic, varying according to the season and the demographics. She could be extracting a fishhook from a tourist’s hand, for example, or giving trauma-informed care to a local with difficult mental health issues. Every consultation is an opportunity to promote health and build health literacy. ‘I want to walk with individuals and families on their health journey,’ Kylie says.
This sense of being with and for a community extends to her community of practice as well. ‘We regularly have a third-year nursing student doing a placement with us,’ she says. ‘It is a privilege to have them for their last placement because it’s a chance to show that nursing practice isn’t just about technical skills but also observing the signs of a person’s social and emotional wellbeing and promoting health and wellbeing.’
Born and bred in a rural community and with most of her adult life in rural and remote parts of the country, Kylie is rock solid in her ‘unconditional positive regard’ for her patients, her staff, and for the students who come to her practice to learn.
And what about the future of primary health care in rural and remote places? ‘I’d like about three more of me!’ she says. Nurse practitioners are few and far between, she adds, with limited Medicare items and rules about bulk billing a barrier to nurse practitioners having a viable career.
Kylie is optimistic about Medicare reforms, though, which will make a big difference to the sustainability of nurse-led practices like hers and the stability of health services in rural communities. The cultural and administrative blocks to anything other than a GP-led practice are a source of frustration. NT Health’s rejection of her formal offer to assist with three recent ‘code yellows’ still rankles (the local hospitals reached capacity),8 because it stopped people from getting care they needed.
She’s grateful for the advocacy of organisations like APNA, the Australian College of Nurse Practitioners, and the College of Mental Health Nurses, saying ‘as well as their work at the “macro” level, they’ve been a lifeline on an individual level.’
Governments must recognise that nurse-led clinics are the future of primary health care. There is no other way to get good health outcomes in rural and remote communities. Obvious as that is, Kylie knows that ‘you have to be a provocateur’ to make change happen.
Caption: Nurse practitioner Kylie Straube (centre) with Selena Uibo MLA, Member for Arnhem (left) and Dheran Young MLA, Member for Daly (right) celebrating the opening of Remote Territory Healthcare (RTHC), the first nurse-led clinic in the NT
References
1. Australian Institute of Health and Welfare (AIHW), Rural and Remote Health, AIHW website, 30 April 2024, accessed 14 October 2024.
2. F Faulks, K Edvardsson and T Shafiei, ‘Barriers and enablers to accessing perinatal health services for rural Australian women: a qualitative exploration of rural health care providers perspectives’, Australian J Rural Health, 2024, 32(4):774–788,
doi:10.1111/ajr.13147.
3. Australian Government, Department of Health and Aged Care, Review of Section 19AB and District of Workforce Shortage (DWS) classification system [discussion paper], General Practice Registrars Australia website, 28 February 2024, accessed 14 October 2024.
4 Australian Government, Department of Health and Aged Care, Working better for Medicare review: health workforce distribution levers, Department of Health and Aged Care website, accessed 14 October 2024.
5. APNA, Advocating to regenerate the rural health workforce with teaching towns, APNA website, accessed 14 October 2024.
6. APNA, Working better for Medicare review: health workforce distribution levers: APNA response, APNA website, 1 March 2024, accessed 14 October 2024.
7. Regional Australia Institute, Understanding regional liveability [discussion paper], Regional Australia Institute website, December 2019, accessed 30 September 2024.
8. ABC News, ‘NT Health calls fourth “code yellow” for Royal Darwin and Palmerston hospitals this year’, ABC News, 9 August 2024, accessed 8 October 2024.
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