summative literature review report - cranaplus...summative literature review report factors...

SummativeLiteratureReviewReport

FactorsEffectingEngagementandDisengagement for

RuralNurses

October2016

__________________________________________________________________________________________________SummativeLiteratureReviewReportFactorsEffectingEngagementandDisengagementforRuralNursesCRANAplusProfessionalServicesOctober2016 Page1of2

EXECUTIVESUMMARY

IstheruralnursingworkforceinAustraliaengagedordisengaged?

CRANAplusrecognisedtherewasavoidinprofessionalrepresentationwithinthehealthindustryforruralnursesandcommissionedtheRuralNursingProject,withtheaimtoidentifyopportunitiesforCRANAplus to be more relevant for Nurses working in rural context of practice. Contemporaryprofessionalpracticeclearlyrecognisestherespectivenursingandmidwiferyprofessions,thispaperdrawsontheparallelsbetweennursingandmidwifery.TheprojectcommencedinJuly2016withtheundertaking of a narrative literature review. The literature review was to explore the means ofengagement and disengagement of rural nurses, in both Australia and the developed countries,namely, New Zealand, Canada, United States, Great Britain and Scandinavia. 700 abstracts werefoundpertainingtothissubjectwith49articlesbeingexamined.Thissummarydocumenthighlightsthekeypointsfromtheliteraturereview.

Thereviewedliteratureacknowledgedthattheruralnurse’sskillsencompassesabroadknowledgeandexpertisebase=generalistapproach.Thepapersindicatedthatthebedrockofourruralhealthservices, nursing and midwifery, had been suffering from the gradual withdrawal of structuralsupports for over twenty years. A change in public policy from one of social welfare to amarketeconomy,causedbyregionalisationandrationalisationofhealthservices.Thishadanegativeimpactonthesmallercommunitiesandsignificantlydeskilledthelocalruralspecialistandgeneralistnurse/midwifethusleadingtodisengagement.

Theerosionofvitalandessentialservicesincludingsurgicalandbirthing,hasseentheslowdeskillingof the rural health workforce. Nurses also expressed their loss of decision making within theirpractice.Thiswasparadoxical,consideringthemorerecentlegislativechangestoendorsetherolesof the nurse practitioner and midwife. These practitioners are a means of adding value andsupporting rural health services. The inflexibility within theworkplace, such as rosters was also afeature of the literature.Nurses sought awork life balance butwith the changes in roles and thedemandsofwork,familiesandlifestylewerecompromised.

Graduate nurses who had begun their careers in the rural areas, reported that they felt poorlyprepared through theirundergraduate studiesandwerenotable tomeet the requiredbreadthofskills as novice nurses. The rural nurse simultaneously struggled with role creep as a result ofcompeting demands of the health service. There was a clear lack of recognition andacknowledgementbytheemployerofthespecialistgeneralist’srolesoftheruralnurseandmidwife.

Rural nurses reported that their preference for Continuing Professional Development (CPD)education was for onsite, face to face training. Inhibitive financial, social and family impacts toattend training,washighlighted, alongwith theneed to gainmanagement support tobe releasedfromwork.

Significant advances in information technology for training includedwebbased training,webinars,onlineresourcesandhighfidelitysimulationhasbeenacknowledgedasimprovingaccesstoongoingeducation, however unreliable internet connections impacted on the usefulness of this form oftraining.Acceptanceofthisdeliverymodewasvariableamongstthegenerationalworkforce.

Arecognisedstrengthoftheruralareaswasthevibrantrelationshipsandinformalnetworks,whichweredeeplyembeddedwithinthelocalculture.Thisprovidedameanstointegrateandsupportthenewgraduateenteringtheworkforceandthosewhohadbeenrecentlyrecruitedfromoverseas.Thisalso led to positive methods of collaboration with community members and was extended to


multidisciplinary health teams to ensure that the breadth of services was available to the ruralcommunitiesinAustralia.

Thekeythemesemergingfromtheliteraturerevieware,• Education

o ContinuousProfessionalDevelopment(CPD)o Undergraduateprogramso TransitiontoProfessionalPractice(TPP)

• Workforcerecruitmentandretentiono Orientation(Culturalandworkplace)

• Modelsofcareo NursePractitionero Nurse(orMidwife)LedCare

• GovernmentPolicy

INTRODUCTION

CRANAplus commissioned the Rural Nursing Project with the aim to identify opportunities for

CRANAplustobemorerelevanttoNursesworking inruralcontextofpractice, including improving

recruitment,retention,professionaldevelopmentopportunitiesandruralpathwayforRuralNursing.

The context of this study we acknowledge the role of the duel qualified Registered Nurse and

Registered Midwife who have traditionally provided the maternity care in the rural setting. This

paper principally refers to Nursing roles unless midwifery was specifically included in the articles

identifiedintheLiteraturereview.EnrolledNurseswereincludedinthisreviewhoweverthereisa

dearthofliteratureregardingtheirroleintheruralsetting.

The project has commencedwith the undertaking of a narrative literature review, to explore the

meansof engagement anddisengagementof rural nurses andmidwives in bothAustralia and the

developed countries of New Zealand, Canada, United States, Great Britain and Scandinavia who

sharesimilarpolitical,social,economicsystems.Thepurposeoftheliteraturereviewwastoprovide

guidanceandshapethequestionsneededfortheproject’sconsultationprocessanddevelopmentof

resources.

Bish,Kenny,&Nay (2015)p382describesanddefines the ruralnurseas specialistgeneralistwho

usesthe‘knowledgeofthecommunity[that]theyresideincombinedwithadvancedclinicalskillsto

provide a nurse led service that responds to the health needs of their community in a contextual

way’.


METHODOLOGY

A narrative literature reviewwas undertaken to investigate factors, which engages or disengages

nursesworkingintheruralareasindevelopedcountriesofAustralia,NewZealand,UnitedStatesof

America,Canada,ScandinaviaandGreatBritain.Eachcountrysharedsimilarorsharedprofessional,

social,politicalandenvironmentalsettings.

Inclusion criteria for the review included both qualitative and quantitative publications in print

between January2014andAugust 2016. TheGriffithUniversity Library cataloguewasutilised and

includedtheScienceDirect,ProQuest,ScopusandCINAHLdatabasesfortheliteraturesearch.

Toachieveabroadperspectiveandunderstandingof ruralnursingthekeywordsselected included

the terms; professional identity, collegiality, motivation, career, membership, professional

development, professional needs and graduate programs. These were then matched against the

primarysearchtermsofruralandnursingandmidwifery.

Theliteraturesearchincludedatotalof748publicationswithafinal49articlesacceptedthatmetall

the inclusion criteria. A thematic analysis was then undertaken of these articles to identify what

engagesordisengagestheruralnurseormidwife.(Braun&Clarke,2006)Fivemainthemesbecame

evident within the research and included: professional development, recruitment, retention,

organisational and government policies that support neoliberalism and corporatisation. These

themes were then further explored and sub groups were identified which described the existing

contextofruralnursingandmidwiferyembeddedwithinthenationalpolitical,social,environmental

and industrialmilieu of the twenty-first century. To further develop the presentation,within the

thematic sub groups, examples have been provided of the extensive research undertaken as

identifiedwithinthisliteraturereview.

THERURALNURSINGANDMIDWIFERYWORKFORCEINAUSTRALIA

To contextualise and gain an understanding of the Australian rural nursing workforce a brief

overview is provided as a means of introduction to the study and does include some data on

midwives.Theruralandregionalareasrepresent27%ofthetotalAustralianpopulation.Theseareas

are known to have higher rates of illness and mortality. They also experience greater barriers in

accessing services through geographical distances and reduced access to health services.(Welfare,

2014)NursesandmidwivesmakeupthelargestworkforceinruralandremoteAustralia.(Bishetal.,

2015; Mills, Francis, McLeod, & Al-Motlaq, 2015) These professions in Australia continue to be

challengedbyanageingworkforce.(Pugh,Twigg,Martin,&Rai,2013).


DataandDefinitions

TheAustralianInstituteforHealthandWelfare(AIHW),publishthe‘NationalHealthandWorkforce

Series’includedwithintheannualpublicationofthe‘NursingandMidwiferyWorkforce’Report.This

publication utilises the Australian Standard Geographical Classification (ASGC) employed by the

Australian Bureau of Statistics (ABS) to classify five major geographic regions; Major cities, Inner

regional, Outer regional, Remote and Very remote.(Pink, 2011). For the purpose of this paperwe

haveusedtheclassifications;InnerandOuterRegions,todefinetheruralareasinAustralia.

TheAIHWusesdataobtainedfromtheworkforcesurveythatisprovidedannuallybytheNursesand

MidwiferyBoardofAustralia(NMBA)toallnursesatthetimeoftheirrenewalofregistration.This

datahasbeenutilisedinthisstudytodescribethecurrentruralworkforcefornurses.

ThetablebelowisadaptedfromtheAIHWpublication,‘NursingandMidwiferyWorkforce2012’and

the 2015workforce data sets published online. There is evidence of a small increase in the rural

workforcesince2012andalsoa7.55%increaseinthe50plusagegroup.Theaveragetotalweekly

hoursworkedremainedsimilarfrom2008to2015,whichwasalsocomparabletothehoursworked

bynursesandmidwivesinthemajorcities.(Welfare,2013,2015)

Inner&OuterRegional 2008 2012 2015Number 79,414 77,742 80,445AverageAge(Years) 45.50 46.35 46.35Age50andover(Percent) 38.55 45.35 46.1Averageweeklyhoursworked 33.15 33.00 33.1FTErate(per1,000population) 1,148.55 1,101.03 1,093.75Population(total) 6,347,479

Table 1: Employed Nurses andMidwives for rural areas (Inner and Outer Regional) selected characteristics2008–2012AdaptedfromNursingandMidwiferyWorkforce2012(Welfare,2013)page31andtheNationalHealthWorkforceDataSet2015DetailedSupplementaryTables(Welfare,2015).

EnrolledNursesalsoconstitute29.06%oftheruralnursingworkforceandworksimilarhourstothe

RegisteredNurse.Thisisdescribedthroughdataadaptedfromthe2014NationalHealthWorkforce

DataSet(AIHW)asprovidedinthetablebelow.(Welfare,2015)

Inner Outer Total


Regional RegionalNumber RegisteredNurses 42,925 19,402 62,327EnrolledNurses 12,122 5,996 18,118AverageHoursWorked AverageRegisteredNurses 32.9 34.3 33.6EnrolledNurses 31.1 31.9 31.5

Table2:EmployedRuralNursesandMidwives2015asadaptedfromtheNationalHealthWorkforceDataSet2015DetailedSupplementaryTables(Welfare,2015)

Theageingandcontractingruralworkforcehasalsobeenreflectedinternationallyinsuchcountries

astheUnitedStatesofAmericaandCanada(K.L.Francis&Mills,2011;McCooletal.,2013;Medves,

Edge,Bisonette,&Stansfield,2015;Nowrouzietal.,2015;Yatesetal.,2011).

ENGAGEMENTANDDISENGAGEMENTFACTORSFORRURALNURSES

Extensive research has been undertaken over the past twenty years to address these ongoing

changesinthehealthworkforceinanattempttomeetthedemandsofthoselivingwithintherural

areas.Thefollowingdiscourserepresentsathematicanalysisoffactors,whichengageordisengages

nurses working in the rural areas of Australia, USA, Canada, New Zealand, Great Britain and

Scandinaviawithinthepastfiveyears(2011to2016.Thefollowingdiagramrepresentsthethematic

analysisoftheliteraturewiththepresentingthemesofengagementanddisengagementwhichfocus

ontheelementsofeducation,recruitment,retention,governmentpolicyandcorporatisation.


EDUCATION• PostgraduateEducation

• Orientation

• Mentoring&

Preceptorship

• ContinuousProfessional

Development

RECRUITMENT• Overseas

Recruitment

• PostRetirement

INADEQUATERETENTIONSTRATEGIES

• Inadequate

Professional

Recognition

• Disempowerment

• LackofAutonomy

INADEQUATEEDUCATION

• Undergraduate

studentplacements

• Postgraduate

educationand

transitionalprograms

• ContinuousProfessional

Development GOVERNMENTPOLICY

• Neoliberalism

CORPOROTISATION

RETENTION• Professional

recognition

• Empowerment

• Autonomy

• AdvancedPractice

(NursePractitioner)

• Networking

• Multi-disciplinary

Collaboration

• CulturalIntegration

• FlexibleWorkforce

DIAGRAMONE:Engagementanddisengagementoftheruralnursingandmidwiferyworkforce

• HighSchoolPrograms

• Undergraduatestudentplacements

• Immersion(students&academics)

• TransitionalPrograms

ENGAGINGTHERURALNURSE&MIDWIFE

DISENGAGINGTHERURALNURSE&MIDWIFE


ENGAGEMENTFACTORSFORRURALNURSES

EDUCATION

AnOverview

The literature reviewhas focusedonengagement factors for thenursingworkforce, frombothan

internationalandAustralianperspective. Engagementbeginswith the introductionofnursingasa

careertolocalhighschoolstudents,whichpromotestheseprofessionsaswellasbeingaprocessfor

potentialrecruitmenttoundergraduateuniversityeducation.(Benavides-Vaelloetal.,2014)

The placement and support for undergraduate students is also a means to recruit nurses and

midwivesback intothecountry. Itrequiresstrongsupportsthroughaclinical facilitatorembedding

the student into awelcoming community and recognising the social qualities of both professional

and personal relationships,which are the cornerstone of a rural community.(Smith, Lloyd, Lobzin,

Bartel,&Medlicott,2015)

Theprovisionof a transitional andpost graduate training that utilises different formsofmedia to

supportdevelopment,suchashighfidelityequipment,butprioritisesopportunitiesforlocalfaceto

faceeducation.(Missen,Sparkes,Porter,Cooper,andMcConnell-Henry,2013).

Strong orientation programs facilitate ameans to provide an overview of the workplace but also

introduce the nurse to the community. This includes cultural orientation for entering indigenous

communities but also for overseas workers who require clarity in communication protocols and

social etiquette.(Dywili, Bonner, Anderson, & O' Brien, 2012; Yonge,Myrick, Ferguson, & Grundy,

2013)

Preceptorship and the role of clinical facilitators were viewed as the preferredmeans to support

students and employees for undergraduate, transitional and orientation programs. Mentoring

createddemandsonthementorwhoalsohaddemandingclinicalroles. Itwastheresponsibilityof

the University to employ clinical facilitators, whichwas promoted by both the students and rural

facilityhosts.Bothgraduatesandundergraduatessoughttoreceiveregularconstructivefeedbackon

performanceandameanstoachievingtheirsetgoals.(Gray&Brown,2016;Mbemba,Gagnon,Paré,

&Côté,2013;Pront,Kelton,Munt,&Hutton,2013)


Theuseofimmersionthroughbushcampsorstudydays,wereusedtoprovideapurviewofrurallife

and prospective work for students and employees. They were also an instrument for academics,

seekingto improvetheirunderstandingand involvement instudentruralplacements. (Deutchman,

Nearing,Baumgarten,&Westfall,2012;Pageetal.,2016;Sutton,Patrick,Maybery,&Eaton,2015)

Allnursesandmidwivesarerequiredtocompletemandatedprofessionaldevelopmenthourstogain

renewaloftheirregistrationwiththeNursesandMidwiferyBoardofAustralia.Toachievethisnurses

indicatedtheirpreferenceforlocallearningactivitieswithfacetofaceinmultidisciplinaryteamswith

clinical placements asopportunities for skill andknowledgedevelopment.(Phillips, Piza,& Ingham,

2012)

RECRUITMENT

Overview

Recruitmenthasbeenanongoing challenge for the rural sector.Opportunities to recruitbeganat

highschools,throughimmersionprojects, invitingstudentsandprospectiveemployeestoattended

workshops located in rural communities. This principle was sustained through undergraduate

placements andby attractingnurses andmidwives into the country for their graduate transitional

programs. While these are potential recruiting opportunities they do need to be appropriately

resourcedwithwell-researchedprogramsthatincludeface-to-facelocalservices,clinicalfacilitators

fundedthroughuniversitiesandregularfeedbackandsupportforprofessionaldevelopmentplans.

Anothermeansistoconsidertheopportunitiesforinvitingthosewhohavechosentoretireorleave

theirprofessionsbyofferingincentivesthatareattractiveandrelevant.Ruralareasareattractiveand

provide ameans towelcome back nurses andmidwives into the localworkforce. (Voit & Carson,

2014)

WORKFORCERETENTION

Overview

Retentionofstaffisdependentonawebofinterlacedfactorswhichincludestheneedfornursesto

berecognisedfortheirworkandstandinginthecommunity.TheNursegeneralisthasabreadthof

skillsandknowledgethatexceedsthegeneralistrole intheurbansetting.There isaclearneedfor

nursestoberecognisedandtofunctionautonomously,withtheunderlyingsupportofmanagersand

governmentpolicymakers.(Hildingssonetal.,2016)


Theroleofnursepractitioners,nurseledclinicsandmidwiferycasemanagersisameanstoensure

thathealthservicesremaininthesmallerruralcommunities.(K.Francisetal.,2014)

Networking both informal and formal as well as interdisciplinary team collaboration is seen as a

strengthinboththeruralandremoteareas.This ispartofbeingcommunityandisanincentiveto

living inthecountryas itprofessionally,personallyandculturallyembedstheworker intothe local

workplaceandtown.(Cox,2003;Crotty,Henderson,&Fuller,2012;Jesse&Kirkpatrick,2013)

Flexibility is also a value that is required by rural nurses which includes the openness of

management,fundersandpolicymakerstosupportalternativemodelsinnursingandmidwiferyled

care.Thisalsoincludesrecognisingthegeneralistrolesofthenursebutalsoidentifyingthatchanges

inworkloadswithincreasedresponsibilitiesneedstobesharedorredistributed.(K.L.Francis&Mills,

2011;Pughetal.,2013)

DISENGAGEMENTOFTHERURALNURSINGWORKFORCE

CORPORITISATIONANDECONOMICRATIONALISATION

Overview

The roleofneoliberalismand the rationalisationof government supported services to the country

continues to impact on the retention and recruitment of rural nurses andmidwives (West, 2013).

Changes in Government public policy has led to centralisation and regionalisation with the

rationalisation of health services and the subsequent withdrawal of services in the smaller rural

communities.Thishashadnegativeimplicationsforthenursingandmidwiferyworkforcewhohave

experiencedchanges intheirownworkplacesandroles.Throughinadequateresourcing,significant

gaps in education, and inadequate workforce retention strategies, the professions have suffered

disengagement.

EDUCATIONALCHALLENGES

Overview

Disengagementforruralnursingiswellrepresentedintheliteratureandthisincludesidentification

of barriers, which inhibit a rewarding learning and working environment. As with the means to

engage undergraduates in the workforce, there still remains barriers to support students in rural


placementswhenresourcesarestretchedandclinicalworkloadsdemanding,aswastheexperience

forsomeTasmaniannursepreceptors.(Zournazis&Marlow,2015)

Post-graduate transitional programs also experience challenges in resourcing regions that are

impacted through restructuring and diminishing infrastructure.(Lea & Cruickshank, 2015) The

graduatealsohasdemandsplacedonthemtohaveabroaderscopeofpracticeandresponsibilities

thanpreparedbyuniversitytraining.Thisleftthemoverwhelmedwithafeelingofbeingabandoned.

(Bennett, Barlow, Brown,& Jones, 2012;Mellor&Greenhill, 2014) Thiswas aggravated by senior

nursesexpectationsforworkreadinesswhichwasbeyondthegraduatesskilllevel,whichbecamea

barrier to the learningenvironmentandnegatively impactedon thegraduatesadjustment to rural

living.(Bennettetal.,2012;Ostini&Bonner,2012)

The requirement tomeetmandated hours of continuous professional development is a statutory

requirement for renewal of registration by theNurses andMidwifery Board of Australia. It is also

fraughtwithchallengesforthoselivingandworkingintheruralsector.Distances,costsoftraveland

accommodation,seeking leaveapprovalandhavingaccess tospecialistcoursesarechallengesthat

continue for the rural nurse and midwife. Understanding the requirements for developing a

professionaldevelopmentplanandusingreflectivepracticewerealsoconcernsthatneedtobemet

bytheprofessionsworkingintheruralsector.(Brideson,Glover,&Button,2012)

RETENTIONCHALLENGES

Overview

Rural nurses felt undervaluedwith imposed changes to their generalist and specialist’s roles. This

created a sense of abandonment by other health disciplines, management, funders and policy

makers.Thiswasexperiencedinthemilieuofasector,whichcontinuedtoplaceincreasingdemands

and expectations on a contracting and aging workforce. Mental health workers and midwives

described,anexpectationforthepractitionertomeetmultipledemandswhilsthavingnomeansto

address inequitableserviceprovisionand lossof rolesandexpertise. Itwasalsoviewedasdivisive

when urban and rural sectors competed for resources and funding particularly the case for the

growing nursing specialities and midwifery led models (Crowther & Ragusa, 2011; Yates, Kelly,

Lindsay,&Usher,2013;Yatesetal.,2011).

Theseexperiencescreatedasenseofdissatisfactionintheworkplace.Increasingworkdemandswith

minimalmanagement support, led to work-life imbalance, particularly when family demands also

increased.(K.L.Francis&Mills,2011;McCooletal.,2013;Pughetal.,2013)


CONCLUSION

The developed countries have similar factors contributing to the engagement and disengagement

impacts on rural nurses. Themixture of government and employer policies and fundingmodels,

recruitment and retention incentives and educational resourcing factors determines the extent of

engagementbynurseswithintheirruralcommunities.Giventhat,itisimportanttorecognisethere

werelimitationswithinthisliteraturereviewontheextentoftheimpactofspecificruralgovernment

policiesandinitiatives,whichhaveeffectedtheengagementofruralnurses.

Contemporary professional practice clearly recognises the respective nursing and midwifery

professions,thispaperdrawsontheparallelsbetweennursingandmidwifery.However,thispaper

has principally referred to Nursing roles unless midwifery was specifically included in the articles

identifiedintheLiteraturereview.Whennursesandmidwivesarerecognisedashealthpractitioners

intheirownright,whoareempoweredtoeitherfulfiltheirgeneralistorspecialistroles,engagement

happens. When Universities appropriately resource and employ clinical facilitators to support

undergraduate student placements, then the future rural workforce is strengthened. When

transitional graduateprogramsoffer comprehensive and supportivementorswho assist to embed

thenurse, intothelocalcommunity,retentionofstaff isa likelypositiveoutcomeandengagement

happens.Withtheuseof immersion,useof technology [i.e.photovoice,audio/visualandnetbase]

culturalintegrationandotherinnovativemeanstoattractandretainstaff,thentheruralworkforce

becomestrulyengaged

There is a great strength that emanates from rural communities who welcome and foster

relationships, which openly welcome the need to attract, support and embed nurses within their

localcommunities. Ruralhealthservicesthatprovideflexibleworkingconditionsandasupportive,

learning environment attract and retain staff, equates to engagement. Provision of educational

programs, tailoredtotheneedsof thenurse/midwife,andareprovided locally isameanstobuild

thecapacityandcapabilitiesoftheworkforce.

Government and government policy makers, funders, educational bodies, employers, and leaders

withinthenursingandmidwiferyprofessionswilldeterminethefutureoftheruralworkforce.Rural

nurses need strong leadership to voice and advocate for the profession and to ensure they are

appropriatelyresourcedtomeetfutureservicedemands.


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