A question of place: medical power in rural Australia

Going the Distance : Ethics of Space and Location on Accessing Reproductive Services in Australia

Qualitative studies on assisted reproductive technology commonly focus on the perspectives of participants living in major metropolises. In doing so, the experiences of those living outside major cities, and the unique way conditions of spatiality shape access to treatment, are elided. In this paper, we examine how location and regionality in Australia impact upon access and experience of reproductive services. We conducted twelve qualitative interviews with participants residing in regional areas across Australia. We asked participants to discuss their experience with assisted reproduction services and the impacts of location on access, service choice, and experience of care, and analysed the data using reflexive thematic analysis, as outlined by Braun and Clarke (2006, 2019). Participants in this study reported that their location impacted the services available to them, required considerable time in travel, and reduced continuity of care. We draw on these responses to examine the ethical implications of uneven distribution of reproductive services in commercial healthcare settings which rely on market-based mechanisms.

Challenges for Medicare and universal health care in Australia since 2000

OBJECTIVES

To identify the financing and policy challenges for Medicare and universal health care in Australia, as well as opportunities for whole-of-system strengthening.

STUDY DESIGN

Review of publications on Medicare, the Pharmaceutical Benefits Scheme, and the universal health care system in Australia published 1 January 2000 - 14 August 2021 that reported quantitative or qualitative research or data analyses, and of opinion articles, debates, commentaries, editorials, perspectives, and news reports on the Australian health care system published 1 January 2015 - 14 August 2021. Program-, intervention- or provider-specific articles, and publications regarding groups not fully covered by Medicare (eg, asylum seekers, prisoners) were excluded.

DATA SOURCES

MEDLINE Complete, the Health Policy Reference Centre, and Global Health databases (all via EBSCO); the Analysis & Policy Observatory, the Australian Indigenous HealthInfoNet, the Australian Public Affairs Information Service, Google, Google Scholar, and the Organisation for Economic Co-operation and Development (OECD) websites.

RESULTS

The problems covered by the 76 articles included in our review could be grouped under seven major themes: fragmentation of health care and lack of integrated health financing, access of Aboriginal and Torres Strait Islander people to health services and essential medications, reform proposals for the Pharmaceutical Benefits Scheme, the burden of out-of-pocket costs, inequity, public subsidies for private health insurance, and other challenges for the Australian universal health care system.

CONCLUSIONS

A number of challenges threaten the sustainability and equity of the universal health care system in Australia. As the piecemeal reforms of the past twenty years have been inadequate for meeting these challenges, more effective, coordinated approaches are needed to improve and secure the universality of public health care in Australia.

Evidence, Emotion and Eminence: A Qualitative and Evaluative Analysis of Doctors' Skills in Macroallocation

In this analysis of the ethical dimensions of doctors' participation in macroallocation we set out to understand the skills they use, how they are acquired, and how they influence performance of the role. Using the principles of grounded moral analysis, we conducted a semi-structured interview study with Australian doctors engaged in macroallocation. We found that they performed expertise as argument, bringing together phronetic and rhetorical skills founded on communication, strategic thinking, finance, and health data. They had made significant, purposeful efforts to gain skills for the role. Our findings challenge common assumptions about doctors' preferences in argumentation, and reveal an unexpected commitment to practical reason. Using the ethics of Paul Ricoeur in our analysis enabled us to identify the moral meaning of doctors' skills and learning. We concluded that Ricoeur's ethics offers an empirically grounded matrix for ethical analysis of the doctor's role in macroallocation that may help to establish norms for procedure.

Nurse experiences and confidence in treating critically ill and injured patients following the completion of the First Line Emergency Care Course

INTRODUCTION

The geographical vastness of Australia in rural and remote regions provides challenges for hospital nursing staff when a medical officer is not immediately available. Delaying treatment until a medical officer arrives can potentially impact on patient outcomes. Some Registered Nurses in rural and remote New South Wales have received advanced training and credentialing through the First Line Emergency Care Course (FLECC) enabling them to initiate treatment prior to the medical officer's arrival. Despite operating since 1990 the course and subsequent model of care has received limited evaluation.

PURPOSE

The aim of this study was to evaluate whether undertaking the First Line Emergency Care Course (FLECC) improves confidence in rural and remote registered nurses' (RN) ability to provide and to initiate extended scope of practice for emergency care of critically ill adults in the absence of a medical officer.

PROCEDURE

A voluntary electronic cross sectional 19 question multi-centre survey was emailed to all nurses FLECC accredited since 2008 and employed in rural and remote Local Health District in New South Wales.

FINDINGS

A response rate of 60% was obtained (225/375). Since credentialing 93.3% nurses had commenced emergency treatments under the approved guidelines. The majority (97.4%) agreed that the course provided the required knowledge. The mean Likert nurse's self-assessed confidence score (1-5) for providing first line response rose significantly (Wilcoxon signed rank test V=375, p-value<0.0001) from 2.47 and up to 3.98 after the course. The majority (83.9%) now had "high" or "very high" confidence.

PRINCIPLE CONCLUSIONS

The FLECC provides registered nurses in rural and remote areas with skills, confidence, knowledge and ability to initiate potentially lifesaving treatment for critically ill or injured patients prior to the arrival of a medical officer. The FLECC model of care helps provide timely care delivery by nurses in rural and remote areas. Further research could examine the differences in outcome in patients treated at sites with FLECC nurses.

Hospitals’ Financial Health in Rural and Urban Areas in Poland: Does It Ensure Sustainability?

Literature review suggests that rural hospitals are in the worst financial conditions due to several factors: They are smaller, located in remote areas, and they provide less specialized services due to their problems with employing well-qualified staff. We decided to check whether it is true in the case of Polish hospitals. Based on the literature review, we have assumed that rural hospitals have less favorable financial conditions. In order to verify this assumption, we use seven indicators of financial health as well as a synthetic measure of financial condition. We have found that, in fact, there is no difference in financial condition between rural and urban hospitals, or even that the financial health of rural hospitals is better if we employ the synthetic measure. Additionally, we have found that the form of activity can be a crucial driver of better financial performance. The concept of rural sustainability is supported by good financial conditions of rural hospitals, which helps to provide better access to medical services for inhabitants of rural areas.

"That Heart Sickness": Young Aboriginal People's Understanding of Rheumatic Fever

High rates of acute rheumatic fever (ARF) and rheumatic heart disease (RHD) in Australia predominate in young Aboriginal people highlighting underlying racial and equity issues.  This article focuses on the perceptions of the disease among young Aboriginal people living in remote Australia. Participant understanding was constrained by clinicians' use of language rooted in biomedicine and delivered through English, a second language for all participants. Clinicians' communicative competency is a social determinant of Aboriginal health. We recommend that the use of Aboriginal languages be prioritized in health services caring for Aboriginal people and that biomedical dominance in the services be relinquished.

Clinical leadership in paramedic services: a narrative synthesis

Purpose

In North America, delegated practice “medical direction” models are often used as a proxy for clinical quality and safety in paramedic services. Other developed countries favor a combination of professional regulatory boards and clinical governance frameworks that feature paramedics taking lead clinician roles. The purpose of this paper is to bring together the evidence for medical direction and clinical governance in paramedic services through the prism of paramedic self-regulation.

Design/methodology/approach

This narrative synthesis critically examines the long-established North American Emergency Medical Services medical direction model and makes some comparisons with the UK inspired clinical governance approaches that are used to monitor and manage the quality and safety in several other Anglo-American paramedic services. The databases searched were CINAHL and Medline, with Google Scholar used to capture further publications.

Findings

Synthesis of the peer-reviewed literature found little high quality evidence supporting the effectiveness of medical direction. The literature on clinical governance within paramedic services described a systems approach with shared responsibility for quality and safety. Contemporary paramedic clinical leadership papers in developed countries focus on paramedic professionalization and the self-regulation of paramedics.

Originality/value

The lack of strong evidence supporting medical direction of the paramedic profession in developed countries challenges the North American model of paramedics practicing as a companion profession to medicine under delegated practice model. This model is inconsistent with the international vision of paramedicine as an autonomous, self-regulated health profession.

From expert generalists to ambiguity masters: using ambiguity tolerance theory to redefine the practice of rural nurses

AIMS AND OBJECTIVES

To redefine the practice of rural nurses and describe a model that conceptualises the capabilities and characteristics required in the rural environment.

BACKGROUND

The way in which the practice of rural nurses has been conceptualised is problematic. Definitions of rural nursing have been identified primarily through the functional context of rural health service delivery. The expert generalist term has provided a foundation theory for rural nurses with understandings informed by the scope of practice needed to meet service delivery requirements. However, authors exploring intrinsic characteristics of rural nurses have challenged this definition, as it does not adequately address the deeper, intangible complexities of practice required in the rural context. Despite this discourse, an alternative way to articulate the distinctive nature of rural nursing practice has eluded authors in Australia and internationally.

DESIGN

A theoretical paper based on primary research.

METHODS

The development of the model was informed by the findings of a study that explored the nursing practice of managing telephone presentations in rural health services in Victoria, Australia. The study involved policy review from State and Federal governments, nursing and medical professional bodies, and five rural health services; semi-structured interviews with eight Directors of Nursing, seven registered nurses and focus group interviews with eight registered nurses.

RESULTS

An ambiguity tolerance model drawn from corporate global entrepreneurship theory was adapted to explain the findings of the study. The adapted model presents capabilities and characteristics used by nurses to successfully manage the ambiguity of providing care in the rural context.

CONCLUSIONS

Redefining the practice of rural nurses, through an adapted theory of ambiguity tolerance, highlights nursing characteristics and capabilities required in the rural context. This perspective offers new ways of thinking about the work of rural nurses, rural nurse policy, education, recruitment, retention and clinical governance.

RELEVANCE TO CLINICAL PRACTICE

A greater understanding of rural nurse practice will assist in achieving positive care outcomes in an environment with competing stakeholder needs, and limited resources and options for care.

An exploration of the longer-term impacts of community participation in rural health services design

This article explores what happened, over the longer term, after a community participation exercise to design future rural service delivery models, and considers perceptions of why more follow-up actions did or did not happen. The study, which took place in 2014, revisits three Scottish communities that engaged in a community participation research method (2008-2010) intended to design rural health services. Interviews were conducted with 22 citizens, healthcare practitioners, managers and policymakers all of whom were involved in, or knew about, the original project. Only one direct sustained service change was found - introduction of a volunteer first responder scheme in one community. Sustained changes in knowledge were found. The Health Authority that part-funded development of the community participation method, through the original project, had not adopted the new method. Community members tended to attribute lack of further impact to low participation and methods insufficiently attuned to the social nuances of very small rural communities. Managers tended to blame insufficient embedding in the healthcare system and issues around power over service change and budgets. In the absence of convincing formal community governance mechanisms for health issues, rural health practitioners tended to act as conduits between citizens and the Health Authority. The study provides new knowledge about what happens after community participation and highlights a need for more exploration.

Gaps in governance: protective mechanisms used by nurse leaders when policy and practice are misaligned

BACKGROUND

Due to large geographical distances, the telephone is central to enabling rural Australian communities to access care from their local health service. While there is a history of rural nurses providing care via the telephone, it has been a highly controversial practice that is not routinely documented and little is known about how the practice is governed. The lack of knowledge regarding governance extends to the role of Directors of Nursing as clinical leaders charged with the responsibility of ensuring practice safety, quality, regulation and risk management. The purpose of this study was to identify clinical governance processes related to managing telephone presentations, and to explore Directors of Nursing perceptions of processes and clinical practices related to the management of telephone presentations to health services in rural Victoria, Australia.

METHODS

Qualitative documentary analysis and semi structured interviews were used in the study to examine the content of health service policies and explore the perceptions of Directors of Nursing in eight rural health services regarding policy content and enactment when people telephone rural health services for care. Participants were purposively selected for their knowledge and leadership role in governance processes and clinical practice. Data from the interviews were analysed using framework analysis. The process of analysis resulted in the identification of five themes.

RESULTS

The majority of policies reviewed provided little guidance for managing telephone presentations. The Directors of Nursing perceived policy content and enactment to be largely inadequate. When organisational structures failed to provide appropriate governance for the context, the Directors of Nursing engaged in protective mechanisms to support rural nurses who manage telephone presentations.

CONCLUSIONS

Rural Directors of Nursing employed intuitive behaviours to protect rural nurses practicing within a clinical governance context that is inadequate for the complexities of the environment. Protective mechanisms provided indicators of clinical leadership and governance effectiveness, which may assist rural nurse leaders to strengthen quality and safe care by unlocking the potential of intuitive behaviours. Kanter's theory of structural power provides a way of conceptualising these protective mechanisms, illustrating how rural nurse leaders enact power.

Community participation in rural health: a scoping review

BACKGROUND

Major health inequities between urban and rural populations have resulted in rural health as a reform priority across a number of countries. However, while there is some commonality between rural areas, there is increasing recognition that a one size fits all approach to rural health is ineffective as it fails to align healthcare with local population need. Community participation is proposed as a strategy to engage communities in developing locally responsive healthcare. Current policy in several countries reflects a desire for meaningful, high level community participation, similar to Arnstein's definition of citizen power. There is a significant gap in understanding how higher level community participation is best enacted in the rural context. The aim of our study was to identify examples, in the international literature, of higher level community participation in rural healthcare.

METHODS

A scoping review was designed to map the existing evidence base on higher level community participation in rural healthcare planning, design, management and evaluation. Key search terms were developed and mapped. Selected databases and internet search engines were used that identified 99 relevant studies.

RESULTS

We identified six articles that most closely demonstrated higher level community participation; Arnstein's notion of citizen power. While the identified studies reflected key elements for effective higher level participation, little detail was provided about how groups were established and how the community was represented. The need for strong partnerships was reiterated, with some studies identifying the impact of relational interactions and social ties. In all studies, outcomes from community participation were not rigorously measured.

CONCLUSIONS

In an environment characterised by increasing interest in community participation in healthcare, greater understanding of the purpose, process and outcomes is a priority for research, policy and practice.

Perceptions of structural empowerment: nurse leaders in rural health services

AIM

To provide insight into the perceptions of structural empowerment of nurse leaders working in rural and regional Victoria, Australia.

BACKGROUND

Fostering nurse leadership in rural health services may be informed by gaining insight into rural nurse leaders' perceptions of structural empowerment.

METHOD

A sample of nurse executives (n = 45) from hospitals throughout rural Victoria, Australia completed the Conditions of Work Effectiveness Questionnaire II (CWEQ-II) aimed to measure structural empowerment.

RESULTS

Rural nurse leaders' perceive themselves to be moderately empowered.

CONCLUSION

The concept of structural empowerment may be useful to inform rural leadership practices.

IMPLICATIONS FOR NURSING MANAGEMENT

Acknowledgement of structural empowerment by nurse leaders may assist in the process of formulating strategies to facilitate an open, honest and responsive culture of patient safety, removing silos, departmental turf issues, and professional territoriality in healthcare services.

In search of attachment: a qualitative study of chronically ill women transitioning between family physicians in rural Ontario, Canada

Background

Most Canadians receive basic health services from a family physician and these physicians are particularly critical in the management of chronic disease. Canada, however, has an endemic shortage of family physicians. Physician shortages and turnover are particularly acute in rural regions, leaving their residents at risk of needing to transition between family physicians. The knowledge base about how patients manage transitioning in a climate of scarcity remains nascent. The purpose of this study is to explore the experience of transitioning for chronically ill, rurally situated Canadian women to provide insight into if and how the system supports transitioning patients and to identify opportunities for enhancing that support.

Methods

Chronically ill women managing rheumatic diseases residing in two rural counties in the province of Ontario were recruited to participate in face-to-face, semi-structured interviews. Interview transcripts were analysed thematically to identify emergent themes associated with the transitioning experience.

Results

Seventeen women participated in this study. Ten had experienced transitioning and four with long-standing family physicians anticipated doing so soon. The remaining three expressed concerns about transitioning. Thematic analysis revealed the presence of a transitioning trajectory with three phases. The detachment phase focused on activities related to the termination of a physician-patient relationship, including haphazard notification tactics and the absence of referrals to replacement physicians. For those unable to immediately find a new doctor, there was a phase of unattachment during which patients had to improvise ways to receive care from alternative providers or walk-in clinics. The final phase, attachment, was characterized by acceptance into the practice of a new family physician.

Conclusions

Participants often found transitioning challenging, largely due to perceived gaps in support from the health care system. Barriers to a smooth transition included inadequate notification procedures, lack of formal assistance finding new physicians, and unsatisfactory experiences seeking care during unattachment. The participants’ accounts reveal opportunities for a stronger system presence during transition and a need for further research into alternative models of primary care delivery.

The balancing point: understanding uptake of advance directive forms in a rural Australian community

OBJECTIVES

The study was conducted in Western Australia, focusing on the attitudes of older, rural, non-hospitalised people towards newly legislated advance care planning (ACP) documents. This study explored baseline awareness and perception of advance directive (AD) forms and factors relevant to their utilisation, using the transtheoretical model as a theoretical framework.

METHODS

Sixty-two adults were recruited from residential aged care facilities, community care organisations, general practice, an oncology service and a law firm. Semi-structured interviews were undertaken. These were transcribed and thematically analysed by the authors.

RESULTS

Participants gave responses that were consistent with different stages of the transtheoretical model. Perceived susceptibility to the negative consequences of not engaging in AD form utilisation was a trigger for further contemplation. The presence of adequate personal empowerment was important for successful completion of AD forms. There was also qualitative evidence of a negative relationship between perceived susceptibility and empowerment regarding AD form utilisation.

CONCLUSIONS

Promoting balance between a person's perceived susceptibility and empowerment may be an effective method of increasing engagement with AD forms.

Urbanization and the utilization of outpatient services under National Health Insurance in Taiwan

OBJECTIVES

This study aims to investigate the relationship between the level of urbanization and the utilization of outpatient services under the National Health Insurance (NHI) program in Taiwan.

METHODS

We adopted a two-part model using data from the 2001 National Health Interview Survey (NHIS) and the 2001 National Health Insurance Research Database (NHIRD) in Taiwan. Data for a total of 20,640 individuals were obtained for subsequent analysis in this study.

RESULTS

The results of the first part, the contact analysis, indicate that individuals residing in areas with lower urbanization levels are less likely to use outpatient services compared to those residing in areas with the highest urbanization levels. The second part of the frequency analysis revealed that, for those individuals that had previously utilized outpatient services, those residing in areas with lower urbanization levels tended to utilize outpatient services less than individuals residing in areas with higher levels of urbanization.

CONCLUSIONS

Our empirical results show that differences between urbanization levels are a major contributory factor associated with the probability and frequency of outpatient utilization in Taiwan.

Complementary and alternative medicine in rural communities: current research and future directions

CONTEXTS: The consumption of complementary and alternative medicine (CAM) in rural areas is a significant contemporary health care issue. An understanding of CAM use in rural health can provide a new perspective on health beliefs and practice as well as on some of the core service delivery issues facing rural health care generally.

PURPOSE

This article presents the first review and synthesis of research findings on CAM use and practice in rural communities.

METHODS

A comprehensive search of literature from 1998 to 2010 in CINAHL, MEDLINE, AMED, and CSA Illumina (social sciences) was conducted. The search was confined to peer-reviewed articles published in English reporting empirical research findings on the use or practice of CAM in rural settings.

FINDINGS

Research findings are grouped and examined according to 3 key themes: "prevalence of CAM use and practice,""user profile and trends of CAM consumption," and "potential drivers and barriers to CAM use and practice."

CONCLUSIONS

Evidence from recent research illustrates the substantial prevalence and complexity of CAM use in rural regions. A number of potential gaps in our understanding of CAM use and practice in rural settings are also identified.

Is a global rural and remote health research agenda desirable or is context supreme?

OBJECTIVE

This paper proposes that there is value in international comparison of rural and remote health-care service delivery models because of practical reasons - to find ideas, models and lessons to address 'local' delivery challenges; and for theoretical reasons - to derive a conceptual framework for international comparison.

METHODS

Literature review and commentary.

FINDINGS

There are significant challenges to international comparative research that have been highlighted generically; for example, equivalence of terminology, datasets and indicators. Context supremacy has been raised as a reason why models and research findings might not be transferable. This paper proposes that there is insufficient knowledge about how rural contexts in relation to health service delivery are similar or different internationally. Investigating contexts in different countries and identifying the dimensions on which service delivery might differ is an important stimulus for study. The paper suggests, for discussion, dimensions on which rural service delivery might differ between countries and regions, including physical geographical factors, social interaction with rurality, policies of service provision and the politics and operation of health care.

CONCLUSIONS

The paper asks whether, given the need to develop models suitable for rural areas and for theory on rural health to extend, international comparative research is an imperative or an indulgence.

Ambiguous and arbitrary: the role of telephone interactions in rural health service delivery

Anecdotal evidence and a limited body of research suggests that telephone interactions between health care consumers and health professionals form an important part of unscheduled health care provision. However, very little is known about these interactions, particularly in the rural context. In rural Australia, there is a need to explore a range of models of service delivery. Telephone-based unscheduled care is one area that demands consideration. By defining unscheduled health care and delineating telephone-based unscheduled health care from other telehealth services, the concepts of formal and informal telephone-based unscheduled health care provision are explored. This article raises previously unasked questions about the role of telephone-based unscheduled health care in the rural context. As a dimension of health care that is poorly understood, the need for further conceptualisation, research and policy development in this area is highlighted.

Emotional toil: psychosocial care in rural settings for patients with cancer

AIM

This paper is a report of a study to identify experienced rural nurses' perceptions of key issues related to the provision of effective psychosocial care for people with cancer in rural settings.

BACKGROUND

A cancer diagnosis has a major impact on psychological and emotional wellbeing, and psychosocial support provided by nurses is an integral part of ensuring that people with cancer have positive outcomes. Although, ideally, people with cancer should be managed in specialist settings, significant numbers are cared for in rural areas.

METHODS

Using a qualitative descriptive approach, three focus groups were conducted in 2005 with 19 nurses in three hospitals in rural Victoria, Australia.

FINDINGS

Participants indicated that a key issue in providing psychosocial care to patients with cancer in the rural setting was their own 'emotional toil'. This Global Theme encapsulated three Organizing Themes- task vs. care, dual relationships and supportive networks--reflective of the unique nature of the rural environment. Nurses in rural Australia are multi-skilled generalists and they provide care to patients with cancer without necessarily having specialist knowledge or skill. The fatigue and emotional exhaustion that the nurses described often has a major impact on their own well-being.

CONCLUSION

In the rural context, it is proposed that clinical supervision may be an important strategy to support clinicians who face emotional exhaustion as part of their cancer nursing role.

Designing a better place for patients: Professional struggles surrounding satellite and mobile dialysis units

The professional claims and struggles involved in the design of non-traditional health care places are rarely problematized in applied health research, perhaps because they tend to fade away once the new design is implemented. This paper offers insights into such professional tensions and their impact on health care delivery by examining the design of two dialysis service delivery models in Quebec, Canada. The satellite units were hosted in two small hospitals and staffed by recently trained nurses. The mobile unit was a bus fitted to accommodate five dialysis stations. It was staffed by experienced nurses and travelled back and forth between a university teaching hospital and two sites. In both projects, nephrologists supervised from a distance via a videoconferencing system. In this paper, we draw mainly from interviews with managers (mostly nurses) and physicians (n=18), and from on-site observations. Nephrologists, medical internists, and managers all supported the goal of providing "closer-to-patient" services. However, they held varying opinions on how to best materialize this goal. By comparing two models involving different clinical and spatial logics, we underscore the ways in which the design of non-traditional health care places opens up space for the re-negotiation of clinical norms. Instead of relatively straightforward conflicts between professions, we observed subtle but inexorable tensions within and beyond professional groups, who sought to measure up to "ideal standards" while acknowledging the contingencies of health care places.

Critical discourse analysis for nursing research

Critical discourse analysis is a useful and productive qualitative methodology but has been underutilized within nursing research. In order to redress this deficiency the research presented in this article represents an exploration of the way in which critical discourse analysis may be applied to the analysis of public debates around policy for nursing practice. In this article the author discusses the history of the application of critical discourse analysis and provides an example of its application to the debate around the use of nurse practitioners within the Australian healthcare system.

Managing patients at risk of deterioration in rural hospitals: A qualitative study

OBJECTIVE

This paper examines strategies used by nurses to manage patients at risk of deterioration in smaller rural hospitals in Victoria, Australia.

DESIGN

A two-stage design comprising a postal questionnaire (n = 20) and case studies (n = 7). Case study participants were interviewed and their practice was observed for one shift.

SETTING

Smaller rural hospitals in Victoria.

PARTICIPANTS

Registered Nurses (Division 1).

MAIN OUTCOME MEASURE

Observed and reported strategies used to manage deteriorating patients.

RESULTS

Nurses in this study used clinical strategies and communication strategies when managing patients who might deteriorate. These strategies were adapted to suit the individual rural context. The ability to anticipate patient requirements and confidence to act on clinical presentation were central. Nurses also had to learn the art of referral and they tailored communication according to their perception of the knowledge and skills of medical colleagues. Strategies were also influenced by staffing patterns and expectations of the community and health service.

CONCLUSIONS

We conclude that rural nurses play an essential role in assessing and managing risk of deterioration across a range of patient presentations and often in challenging situations. Strategies used by nurses required an understanding of the rural context of care delivery.

Trends in rural and urban differentials in incidence rates for ruptured appendicitis under the National Health Insurance in Taiwan

OBJECTIVES

Rural-urban disparities in health remain a major focus of concern. This population-based study examined the performance of Taiwan's universal healthcare system in reducing rural-urban disparities in health, through better accessibility. Changes in the rates of ruptured appendicitis were compared between residents of remote and non-remote areas in Taiwan, under the National Health Insurance (NHI) programme.

METHODS

We identified all 128,930 patients undergoing appendectomy in Taiwan between 1996 and 2001. The NHI inpatient files, enrolment files, major disease files, hospital registry and the household registry were linked to provide comprehensive individual and hospital information. Probit regression analyses were used to obtain adjusted estimates.

RESULTS

During the first 3 years, although the differences between the remote and non-remote areas were apparent, they were seen to be narrowing. This downward trend continued, and, since 1999, few discernible differences have been observed. After adjusting for individual and hospital characteristics, over time, the ruptured appendix rate among remote area residents was seen to be decreasing significantly faster (1.1%) than among non-remote area residents. More specifically, the children showed a substantially steeper narrowing trend (3.3%) in rural-urban disparities, than did adults.

CONCLUSIONS

Our findings have shown a significant narrowing of health disparities between remote and non-remote populations, resulting from free access to care and more healthcare provision in remote areas under the NHI programme; particular success has been observed in rural children. Although certain disparities still exist, Taiwan's universal healthcare system has effectively reduced rural-urban disparities in access to care and in ultimate health outcomes.

Task substitution: where to from here?

Meeting future health workforce needs is a challenge for all health professionals.

How place matters: unpacking technology and power in health and social care

The devolution of care into nontraditional community-based settings has led to a proliferation of sites for health and social care. Despite recent (re)formulations of 'evidence-based' approaches that stress the importance of optimizing interventions to best practice by taking into account the uniqueness of place, there is relatively little guidance in the literature and few attempts to systematically 'unpack' key dimensions of settings most relevant to policy, practice and research. In this paper, we explore how place matters for health and social care. In effect, we propose making place the lens through which to view practice, and not simply an interesting sideline focus. We focus specifically on (a) the emplacement of power relations in health and social care in and across settings; and (b) the pervasive (and often unrecognised) influence of technology on and in place (both 'mundane' and more visible 'high' technologies) as arguably among the most significant and pervasive (and often overlooked) dimensions of place pertinent to health and social care in both traditional (institutional) and nontraditional (community) settings. Drawing on diverse disciplinary literatures, we seek to make visible certain issues and bodies of work that health professionals may not be aware of, and which often remain inaccessible to practitioners and applied researchers on account of their density, complexity, and specialised terminology. In particular, drawing on the rich tradition of cultural studies, we advance the culture of place as a rubric for understanding the complex interrelationship between power, technology, culture, and place. Several fruitful avenues for place-sensitive research of health and social care practice (and its effects) are suggested.

An online study of Australian Enrolled Nurse conversion

AIM

This paper reports the findings of a study exploring the reasons why rural Enrolled Nurses have chosen to convert to level 1 of the nursing register.

BACKGROUND

Whilst the Project 2000: A New Preparation for Practice report resulted in the cessation of second level or Enrolled Nurse training in the United Kingdom, Australia has continued to educate enrolled nurses. Currently Australia is facing critical shortages of level 1 nurses and nowhere is this more acute than in rural areas. There are indications that there are large numbers of rural Enrolled Nurses who are interested in 'converting' from level 2 to level 1 of the nursing register.

METHOD

Using a computer program that facilitates engagement and interaction, an 'online' focus group was conducted with 38 Enrolled Nurses undertaking a conversion programme at a rural university in Victoria, Australia. During a period of 2 months the Enrolled Nurses participated in a discussion focusing on their reasons for undertaking a conversion programme. Their responses were categorized into five interrelated broad themes.

FINDINGS

These Enrolled Nurses suggested that disillusionment with their role and role ambiguity were the primary reasons for their decision to undertake a conversion programme. All participants suggested that their scope of practice as an Enrolled Nurse is significantly broadened in rural areas. They argued that, following conversion, they are in an ideal position to manage the diversity of rural nursing practice.

CONCLUSIONS

In Australia, Enrolled Nurse conversion has the potential to ease some of the workforce shortages, particularly in rural areas. By supporting Enrolled Nurses to undertake conversion programmes, rural areas may benefit from having nurses with the knowledge and skills to deal with the rural environment.

Why 4 years when 3 will do? Enhanced knowledge for rural nursing practice

In Australia, debates over the appropriate length of undergraduate nursing programs have a long history. Submissions from both universities and industry to key government reports have consistently argued that the current minimum entry level of practice, a three-year program, is too short to enable students to gain the knowledge and skills necessary for the contemporary nursing role. Despite these submissions, the established entry level for nursing practice in Australia remains a three-year undergraduate bachelor degree. However, there is a small group of high-achieving students who will begin practice at the end of a four-year program. Little is known about these programs, or the students who are currently enrolled in them. Designed as a collaborative endeavour, based on co-operative inquiry, the study discussed in this article aimed to provide an insight into aspects of a four-year undergraduate nursing program. Potentially, the broader theoretical and clinical preparation that is possible in a four-year program provides students with enhanced learning opportunities that will enable them to graduate with more confidence and greater ability. In this study a four-year program provided an opportunity for a regional university to prepare students for the demanding realities of a complex area of practice, rural nursing.