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Health policy and rural nurses: a time for reflection
Health policy and rural nurses: a time for reflection Dirk M Keyzer ABSTRACT: - The purpose of this paper is to discuss the rural health policies of the federal and Victorian governments and the challenges to the nursing workforce. The discussion will centre on the separation of the purchaser and provider functions of the public sector management teams, the fiscal policies of Casemix, the Care Aggregated and Standard Aggregated Modules (CAM/SAM) and the possibilities for creating new nursing roles (Commonwealth 1991, 1994; DH&CS 1993, 1994). The focus is on the direct challenge to the traditional distribution of power and the principles of social control in health care services. The renegotiation of the established order demands careful management of the knowledge and change required to secure the nursing profession's role in a changing society.
INTRODUCTION The federal government's strategy for the r u r a l h e a l t h s e r v i c e , t o g e t h e r w i t h the Victorian government's fiscal policy, will b r i n g r a d i c a l c h a n g e s to h e a l t h service providers and health care workers. Any attempt to redistribute resources immediately challenges the control exerted by powerful groups within the service; in p a r t i c u l a r the m e d i c a l p r o f e s s i o n . The i m p l e m e n t a t i o n of n e w h e a l t h policies, therefore, b r i n g s i n t o p l a y the political p o w e r of the medical profession and its control over the division of labour in health care. In order to discuss the impact of government policy on rural nursing practice the term 'policy' must be defined and the complex p r o c e s s e s i n v o l v e d in formulating government decisions highlighted. Government policies differ not so much in the aims as in the means of pursuing them. The r o u t e from p o l i c y - m a k i n g to implementation is far from linear. Gardner (1989,1992) d i s c u s s e d t h e p o l i t i c a l complexities s u r r o u n d i n g the m a k i n g of health policy and its implementation in the public sector services, and argued that the results are a c o m p r o m i s e by those w i t h vested interests in the outcomes. Health policy, therefore, involves both the politics of, and in, nursing. Discussion on health policy must include nursing policy and its source. Throughout this paper reference is made to the public sector.
HEALTH POLICY The word 'policy' is one that we have all used at some time in our working lives to defend or support some nursing action. We use the word with such carelessness that
others could criticise us for employing it in m u c h the same w a y that a d r u n k uses a l a m p post: m o r e for s u p p o r t t h a n illumination. A simple dictionary definition of the term i n d i c a t e s t h a t policy is a p l a n of action a d o p t e d or p u r s u e d by an i n d i v i d u a l , government, party or business. Palmer and Short (1989) discuss the complex ways in which the term is used to describe different types of statements, intentions and actions associated with the various agencies that make u p a health service. They p r o v i d e examples of the different sources that may be used to determine a government's policy. These sources include: the interpretation of parliamentary speeches; comments made by politicians; the past and present actions, or i n a c t i o n , t a k e n by g o v e r n m e n t , a n d statements made by government about its future intention. The media also play a role in i d e n t i f y i n g , a n a l y s i n g a n d s h a p i n g g o v e r n m e n t policies, not to m e n t i o n the s h a p i n g of the p u b l i c ' s a t t i t u d e s a n d responses to these policies. Policies are s h a p e d by a m u l t i p l i c i t y of socioeconomic and political factors. This is exemplified in the federal g o v e r n m e n t ' s rural health strategy, which identifies the diversity of rural Australia and the health services required to meet the d e m a n d s of local populations throughout the country (Commonwealth 1994). The rural health policies adopted by the federal and state governments are redistributing in nature. They a r g u e for a relocation of resources a w a y from services b a s e d on e x i s t i n g facilities t o w a r d s s e r v i c e s b a s e d on expressed demand. The implementation of this redistributing strategy is a radical change in the allocation
of resources. It challenges traditional models of service d e l i v e r y a n d p o w e r b a s e s , including that of the nursing profession. The rural health strategy's recommendations offer real opportunities to match the supply and demand for health care in rural areas and to promote the role of the advanced n u r s i n g practitioner (Coxhead 1993). The strategy recommends that existing nursing roles in rural and remote areas be formalised and legitimised to ensure a better service for local populations (Commonwealth 1994; DH&CS 1994). Changes of this nature require careful management of change and the education central to achieving the desired outcomes. We m u s t expect t h a t the v a r i o u s p o w e r holders will engage in political activities to either m a i n t a i n the s t a t u s quo or to manipulate a compromise in their favour. Attempts to legitimise the role of the 'Nurse P r a c t i t i o n e r ' will s e r i o u s l y d i s t u r b the
Attempts to legitimise the role of the 'Nurse Practitioner' will seriously disturb the division of labour in health care ... division of labour in health care and the right of the medical profession to control the job c o n t e n t of n u r s e s , a n d they t h e r e f o r e constitute a public challenge by the nursing profession to control its practice and future development. There is a real danger that the medical profession could use its traditional power to convert the 'Nurse Practitioner' role into that of a 'Physician's Aide'. The nursing profession, therefore, must have its policies and strategies in place, to enable it to defend nursing, to take its place at the negotiating table and to ensure that rural nurses can develop as advanced practitioners of nursing. In considering a specific health policy we m u s t a t t e n d to the interrelationship of a number of socioeconomic factors, how these affect the health of the population, and the need for all government sector agencies to consider the effect the outcomes of their policies have on the health of the nation (Sax 1990). Analysis of any government's health policy must take into account its policies for e d u c a t i o n , social s e c u r i t y , h o u s i n g , the environment, trade and industry, and the impact of these on the health of individuals, groups and populations. The rural health
strategy (Commonwealth 1994) draws our attention to the inequalities in health and their linkages to social inequalities based on age, gender, race, occupation and status w i t h i n the social s t r u c t u r e . I n d i v i d u a l s , therefore, have health problems because they are members of a specific community and not because they are individuals. Health services s h o u l d focus on the specific n e e d s of communities rather than on the existence of a p a r t i c u l a r service in a specific location ( C o m m o n w e a l t h 1994; DH&CS 1994). Furthermore, we need to ensure that service models meet the future needs of communities and not the perceptions of specific health care professionals or power brokers. The nursing profession will have to scrutinise its present f r a m e w o r k s for p r a c t i c e b a s e d on individualism if it is to prepare practitioners w h o can meet the n e e d s of p o p u l a t i o n s . The c e n t r a l role of the n u r s e in r u r a l c o m m u n i t i e s is clearly a r t i c u l a t e d by McMurray (1993) when she describes the d i v e r s i t y of the role in t e r m s of social advocacy, counselling, health education and t r a n s p o r t a t i o n c o n s u l t i n g as well as the provision of direct care. McMurray argues for a stop to the standardisation of health care and nursing practice across the country and negates the notion that rural communities must change according to the dictates of urban rationalists (McMurray 1993). It could also be argued that continued definition of the nurse's role as that of an employee of a p a r t i c u l a r service r a t h e r t h a n as a professional is the main source of this need for tight role definitions, job specifications, procedure manuals and the like. One cannot imagine the medical profession debating the definition of its practitioners' roles and the scope of professional practice in this manner. There is a d e a r t h of r e s e a r c h on h e a l t h services in small rural communities. While there are several strategies for rural health services no one a p p e a r s to be willing to define the exact n a t u r e of a ' g o o d ' rural health service. The protocols for health gains in rural areas are still to be written. There is unlimited scope for nursing research into the d e m a n d , s u p p l y and outcomes of health services in rural a r e a s . Most of o u r information on the work of rural nurses is to be found in descriptive journal articles and conference p a p e r s . These s o u r c e s , nevertheless, do provide insights into the challenges to the status quo being mounted by practitioners. This is exemplified by
Burley and Harvey (1993) in their study of three rural Gippsland towns. The study is e m b e d d e d in the c u r r e n t reforms of the health service in Victoria and acknowledges the c h a n g e s t a k i n g p l a c e in t e r m s of downsizing, or closure, of health services in r u r a l c o m m u n i t i e s . Burley a n d H a r v e y (1993) support McMurray's definition of the d i v e r s i t y of the r u r a l n u r s e ' s role a n d consider that this very diversity provides rural nurses with unique insights into the needs of their communities. The researchers a r g u e t h a t it is t h e s e n u r s e s ' b r o a d k n o w l e d g e of their c o m m u n i t i e s w h i c h enables them to practise effectively in the rural setting. The data provided by this study supports the profession's central position: that rural nurses are ideally placed to provide a clear
... rural nurses are ideally placed to provide a clear indication about potential health service delivery options... indication about potential health service delivery options and the value of each to their community. If the V i c t o r i a n g o v e r n m e n t ' s h e a l t h policy is p r o p e r l y implemented, then nurses must be involved in the identification of the p o p u l a t i o n ' s needs for health care and in the formulation of the Health Authority's strategic intents and directions for the rural health service. S u p p o r t for this s t a n c e , a n d for the development of advanced practitioner roles for r u r a l n u r s e s , can be f o u n d o u t s i d e Australia. The 1993 W o r l d D e v e l o p m e n t R e p o r t , 'Investing in Health', focuses mainly on the provision of cost-effective health services worldwide. The r e p o r t c o m m e n t s e x t e n s i v e l y on the cost-effective use of h u m a n r e s o u r c e s a n d d e m o n s t r a t e s the a n o m a l i e s in h e a l t h h u m a n r e s o u r c e utilisation around the world. The World Bank argues in favour of the utilisation of 'Nurse Practitioners' (Coxhead 1993) and highlights the benefits derived in terms of cost-effective services. The challenge for A u s t r a l i a n r u r a l and u r b a n n u r s e s is to m a k e visible their w i d e r p o t e n t i a l
contribution to the cost-effective promotion of the c o u n t r y ' s health. This, h o w e v e r , demands proper utilisation of information technology by practitioners, to quantify and qualify clients' demands for, and outcomes of, nursing care. Similarly, the evaluation of the o u t c o m e s of n u r s i n g care w o u l d be e n h a n c e d by g r e a t e r i n v o l v e m e n t of researchers in quantitative research dealing with the issues surrounding a cost-effective workforce. This was exemplified by one n u r s e m a n a g e r c o l l e a g u e w h e n she complained that our researchers appeared to be f o c u s i n g all t h e i r a t t e n t i o n on peripheral issues rather than providing the d a t a she r e q u i r e d to d e f e n d n u r s i n g in committee. This may be anecdotal evidence, b u t it does merit serious c o n s i d e r a t i o n . H e a l t h care p o l i c i e s b a s e d solely on epidemiological data cannot address these socioeconomic and political variables, or the involvement of a variety resource holder, social groups and service managers in the s u p p l y a n d d e m a n d for h e a l t h care (Commonwealth 1994). Ministers, however, are held to account for the policies they a d o p t a n d t h e d e g r e e to w h i c h their d e p a r t m e n t s scrutinise their policies for h e a l t h c o n s e q u e n c e s . The g o v e r n m e n t departments, therefore, should provide the help and assistance required by regions and health authorities to develop local health care strategic plans tailored to the needs of their c o m m u n i t i e s . G o v e r n m e n t cannot expect local managers to reconstruct their m o d e l s for service delivery w i t h o u t the e d u c a t i o n a l r e s o u r c e s to s u p p o r t the changes required. This draws our attention o n c e m o r e to the p o l i t i c a l a c t i v i t i e s surrounding the new rural health policy and nursing's access to vital resources. NEW POLICIES FOR O L D The N a t i o n a l R u r a l H e a l t h S t r a t e g y (Commonwealth 1994) identifies the need for state and territory health authorities to develop strategic frameworks reflecting the social and economic compositions of their populations, the nature of the population c h a n g e , g e o g r a p h i c l o c a t i o n a n d the d i s t a n c e of t h e c o m m u n i t y from major service centres. The difficulty for nurses in d e t e r m i n i n g the o u t c o m e s of their contributions is the continued inappropriate focus on nursing work in isolation from the i n p u t of o t h e r s . I n s t e a d of an isolated nursing audit we should be focusing on a
clinical audit of a health care team and an a u d i t of t h e c o m p l e t e service to t h e p o p u l a t i o n . This d o e s n o t i m p l y t h a t n u r s i n g a u d i t s d o n o t c o n t r i b u t e to t h e overall audit of the service. The argument is t h a t w e c a n n o t v i e w the i n p u t of o n e professional g r o u p in isolation from the input of other health workers and lay carers. The Rural Health Strategy (Commonwealth 1994) recognises the need for a well-qualified workforce within the rural health services and recommends a review of our existing recruitment of rural students, the contents of under and postgraduate programs in terms of clinical placements in rural areas. The s t r a t e g y also q u e s t i o n s the r e l e v a n c e of urban-based university courses to the actual w o r k u n d e r t a k e n by r u r a l n u r s e s . T h e implementation of the rural health strategy, therefore, demands a radical review of our existing curricula and the selection of clinical
The difficulty for nurses ... is the continued inappropriate focus on nursing work in isolation from the input of others. placements for our undergraduate students. It also raises the question of the status we afford the urban-based education centre over the regional campus. The federal policy for the health of the nation (Commonwealth 1991, 1994; DH&CS 1993) aims to improve the care provided through: ongoing care across services; reductions in hospital lengths of stay; the expansion of outpatient services and home-based care. The latter c h a l l e n g e s our historical a n d i n a c c u r a t e s e p a r a t i o n of h o s p i t a l a n d community-based services. It questions the supremacy of the training hospital as the major source of health care and, in turn, the medical profession's power base as well as n u r s i n g ' s t r a d i t i o n a l career p r o f i l e . F u r t h e r m o r e , this policy s u g g e s t s a relocation of resources from the h o s p i t a l towards the community, with a corresponding redeployment of staff when r e s o u r c e s follow the p a t i e n t i n t o t h e community. The policy, therefore, raises questions about the resources necessary to re-educate hospital nurses for their new roles in the community sector and to renegotiate the established division of work within the nursing profession. ROYAL COLLEGE OF NURSING AUSTRALIA
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The federal g o v e r n m e n t ' s policy for the relocation of resources does not m e a n a reduction in health care resources. It simply suggests that we should relocate those resources a c c o r d i n g to the p o p u l a t i o n ' s e x p r e s s e d d e m a n d s for care. The fiscal policy u n d e r p i n n i n g C a s e m i x d o e s n o t automatically demand reduced resources for the health service. Casemix is only a funding formula and should not be confused with the underlying political decisions regarding total expenditure on the public health service. Casemix may be focused on p a y m e n t for services provided, b u t the DH&CS (1994) a n d the N a t i o n a l Rural H e a l t h S t r a t e g y (Commonwealth 1994) readily acknowledged that there are still problems of a c c u r a t e l y m e a s u r i n g the o u t c o m e s of services provided by hospitals, including the reimbursement of nursing services. Nurses, t h e r e f o r e , m u s t a d d r e s s the i s s u e s s u r r o u n d i n g the o u t c o m e s of n u r s i n g interventions before others do it for them. This in t u r n d e m a n d s our p r o p e r use of information technology to collect, collate and analyse the data we require, to provide costeffective n u r s i n g s e r v i c e s to m e e t a population's expressed demands for nursing care. The DH&CS (1993), in c o m m o n with the federal government, also drew attention to the n e e d for g r e a t e r s c r u t i n y of the m a n a g e m e n t of health care resources. It questioned the traditional models for service delivery and the means of securing the best value for money spent on health services. DH&CS p o l i c i e s d r a w h e a v i l y on the a p p l i c a t i o n of g e n e r a l m a n a g e m e n t principles to the delivery of health services. The advent of managerialism in health care organisations seriously challenges our right to determine our job content and the scope of our professional practice. General managers have the right to determine the division of l a b o u r in their o r g a n i s a t i o n s and to determine the contributions each section of the workforce will make to achieve those managers' operational goals. The longer we define the nurse's role in terms of being an e m p l o y e e of a specific service a n d o n e , therefore, who is closely related to the work of hospital doctors, the more we reinforce the manager's right to define and control the scope of our professional practice. The federal and Victorian state governments h a v e p u r s u e d the goal of cost-effective services by separating the purchaser and p r o v i d e r f u n c t i o n s of the p u b l i c sector jCOLLfiGIAN VOLUME 2 (1) JANUARY 1995
management teams (DH&CS 1993). Thus, the state government's policy emphasises the p r i m a c y of the m a r k e t p l a c e in determining the quality and add-on value of the h e a l t h care p r o d u c t . C o m p e t i t i o n between service providers is viewed as the m o s t effective m e a n s of e n s u r i n g cost containment and increased quality. Service m a n a g e r s are n o t in c o n t r o l of all the variables and cannot, therefore, manipulate the m a r k e t to their a d v a n t a g e . General m a n a g e r s m u s t be able to negotiate any c h a n g e s in the service w i t h the medical profession, which is unlikely to relinquish any of its traditional power and will use its advantage to increase its power base in the new organisation. The major variables out of the m a n a g e r ' s control are medicine's ability to fuel the p u b l i c ' s d e m a n d s for s o p h i s t i c a t e d technological services and the control it
The longer we define the nurse's role in terms of being an employee ... the more we reinforce the manager's right to define and control the scope of our professional practice. exerts over the supply of health services by virtue of the training of doctors. The service managers will have to rely on quality control m e a s u r e s to confine the activities of the m e d i c a l p r o f e s s i o n w i t h i n their p r e s e t b u d g e t s . Similarly, the change t o w a r d s c o m m u n i t y - b a s e d care m a y be n o t h i n g more than the colonisation of the community by the hospital services. This d i l e m m a , c o m p o u n d e d b y t h e c o m p l e x i t i e s of c h a n g e i n h e r e n t in any policy a n d action w h i c h c h a l l e n g e s t r a d i t i o n a l p r a c t i c e s in a b u r e a u c r a t i c organisation, is further complicated by the conservative nature of rural communities. Resistance to change may be encountered not so much on the basis of its relevance to the population's needs for health care but on its break with past behaviours, norms and styles. Unfortunately, nursing will be asked to challenge the status quo from a position of social and organisational weakness, unless o u r r e s e a r c h e r s and p r a c t i t i o n e r s can p r o v i d e our n e g o t i a t o r s w i t h e m p i r i c a l ' h a r d ' d a t a on the cost-effectiveness of clinical practice.
THE IMPLICATIONS FOR RURAL HEALTH SERVICES The N a t i o n a l H e a l t h S t r a t e g y a n d the National Rural Health Strategy (Commonwealth 1991, 1994) highlight the constraints imposed by past fiscal policies on all rural communities and their difficulty in tailoring services to meet their needs. Rural c o m m u n i t i e s often lack the p o p u l a t i o n necessary to secure funding for a mix of hospital, supported residential, community and home care. The National Rural Health Strategy (1994) also draws attention to the inadequate databases required to provide services based on m e a s u r e s of the rural population's health status. Furthermore, the DH&CS (1993) describes the n e w health policy in terms of rewarding hospitals for increased t h r o u g h p u t - treating more patients with lengthy and complex procedures. Thus, not only does the new system differ from the old average b e d / d a y costs system, it also appears to favour the large 'magnet' urban hospital over its rural g e n e r a l i s t c o u n t e r p a r t . Strasser (1994) argues from a medical perspective that the new policy does not serve rural communities well. G i v e n the m e d i c a l p r o f e s s i o n ' s position within the new national rural health unit housed in Moe, Victoria, that profession is in a position to promote and secure its boundaries in rural health care regardless of the impact of the new policy on the health of the nation. I n d e e d , it p r o v i d e s a p r i m e example of the distribution of power and control within the health services. Tn an era of economic recession the rural areas face three major health-related issues: r e d u c t i o n in the size of the p o p u l a t i o n leading to reduced health care resources; the retraction of some hospital-based services i n t o r e g i o n a l c e n t r e s , a n d the n e e d to demonstrate an infrastructure incorporating good health care resources to attract new industries to their regions. This view of a general recession in rural areas is challenged by the Kinsey Report (1992). Kinsey clearly states that, while some rural areas may be experiencing an economic recession, this is not true of all regions throughout Australia. A c c o r d i n g to Kinsey, the available data suggests that the economies of some rural areas are g r o w i n g faster t h a n the major metropolitan areas. The use of Diagnosis-Related Groups as a way of paying for services indicates a major swing away from resource allocation based
on a n t i c i p a t e d care t o w a r d s p a y m e n t for actual care provided. The DH&CS review of small rural hospitals (1994) argues that the redistribution of resources from high cost, u n d e r - u s e d bed-based services t o w a r d s a community-based service will result in a more appropriate, comprehensive and accessible service for rural populations. The resultant closure of beds, however, could be used by those persons resisting change to claim that the real policy is o n e of r e d u c e d p u b l i c spending. The DH&CS (1994) disclaims such arguments by providing examples of 'best practice' in the Macarthur and Lakes Entrance areas of Victoria. The DH&CS claims success for Casemix. This claim is not contested by the federal Minister for Health, Dr Lawrence, w h o h a s a c c u s e d V i c t o r i a ' s M i n i s t e r of Health, Mrs Tehan, of taking all the credit for the new fiscal policy. The federal minister's s u p p o r t for C a s e m i x d o e s i n c l u d e t h e
We may ... see the redeployment of nurses within the rural hospital service and between the hospital and community service, in parallel to similar adjustments in the urban services. statement that a Labour government m a y have pursued the policy differently from the present state g o v e r n m e n t in Victoria (The Australian, T h u r s d a y May 26, 1994:4).
IMPLICATIONS FOR RURAL NURSES There are small clusters of rural hospitals, r e s u l t i n g in a n u n e v e n g e o g r a p h i c a l distribution of resources. The DH&CS (1994) has s u g g e s t e d that in these locations the h o s p i t a l s s h o u l d form a c o n s o r t i u m to p r o v i d e an i n t e g r a t e d service in w h i c h hospital beds are located in larger centres. T h u s , the policy a p p e a r s to s u p p o r t t h e formation of regional centres. This will have a d i r e c t i m p a c t on the e m p l o y m e n t a n d distribution of nurses. We may, therefore, see the redeployment of nurses within the rural hospital service and between the hospital and c o m m u n i t y service, in parallel to similar a d j u s t m e n t s in the u r b a n services. T h e concept of multiskilling in nursing practice may involve not only the extension of nursing
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practice into other health workers' areas of practice but also the ability to move between hospital and community settings and between the different 'specialist' clinical areas. We m a y even w i t n e s s a r e d e f i n i t i o n of the d i v i s i o n of l a b o u r in h e a l t h a n d the emergence of new health care occupational groups. There is a distinct possibility that n u r s i n g will be d r a w n closer to m e d i c a l practice and that direct care-giving activities will be carried out by vocationally-trained support workers. Thus the organisational strategies developed in the hospitals of the m i d - 1 9 t h c e n t u r y will be a d a p t e d a n d p e r p e t u a t e d w e l l into the 21st c e n t u r y . Rural and remote area health services have recruitment and retention problems (DH&CS 1994). Rural n u r s e s m a y be tied to their employment base through family commitments and are not free to relocate to n e w areas of e m p l o y m e n t . F u r t h e r m o r e , rural women often have to contribute to the w o r k on their families' farms and this is reflected in their work patterns. The service may require a relocation of resources, but its major r e s o u r c e m a y be tied to a specific location and pattern of shift work. Thus, new r e c r u i t m e n t a n d r e t e n t i o n policies are required. Managers will have to create new a n d a t t r a c t i v e n u r s i n g jobs to entice e x p e r i e n c e d n u r s e s to fresh l o c a t i o n s . The creation of the Rural Health S u p p o r t Education and Training (RHSET) program by the federal Minister for Health, Housing and C o m m u n i t y Services has opened u p new opportunities for nurse educationists and r e s e a r c h e r s to i m p l e m e n t c h a n g e in the practice of rural n u r s e s ( C o m m o n w e a l t h 1994). The establishment of medical Rural Health Training Units in several states, and the National Rural Health Unit in Victoria, has given new impetus to the establishment of multidisciplinary Rural Health Training Units (National Rural Health Strategy 1994). These Rural Health Units, however, were established mainly to recruit doctors to rural areas. A great deal of work will need to be carried out to convince the nursing profession t h a t t h e r e are s t r a t e g i c benefits for p r a c t i t i o n e r s in b e i n g d r a w n into a ' m u l t i d i s c i p l i n a r y ' u n i t d o m i n a t e d by medicine. The c r e a t i o n of a ' m u l t i disciplinary' unit under the auspices of the rural health strategy (DH&CS 1994) could simply provide the medical profession with yet another base from which to maintain its p o w e r a n d c o n t r o l over the d i v i s i o n of
COLLEGIAN VOLUME 2 fl) JANUARY 1995 ,
labour in health care. If this were to happen, then there would be no advantage to the nursing profession in joining such a unit; nor would we expect to see any changes in the i l l n e s s - o r i e n t a t e d h e a l t h services of the present. The success or failure of the new health policy lies in the DH&CS political will to challenge the traditional orthodoxy of the health services that 'doctor knows best'. The nursing profession does have an opportunity to hold the balance of power in this political tussle and to secure its place in the future service.
CONCLUSION The reforms of the rural health services draw our attention to the f u n d a m e n t a l issues facing governments throughout the world: the d i s t r i b u t i o n of h e a l t h r e s o u r c e s according to the population's needs and the delivery of cost-effective services. The role and place of nursing within these strategies is clearly identified as a major resource and one that is not being utilised to its maximum potential. We cannot ignore the impact of the political e c o n o m y of h e a l t h on our control over our future roles and remits.
A NURSING POLICY UNIT The wide range of changes implicit in the strategies for health set out at both federal and state levels of g o v e r n m e n t p r e s e n t s strong arguments in favour of creating a Nursing Policy Unit. This agency would be actively involved in the formulation of all
... work will need to be carried out to convince the nursing profession that there are strategic benefits for practitioners in being drawn into a fmultidisciplinaryf unit dominated by medicine. nursing policy, in researching the outcomes of present policy and in acting as a source of advice for those formulating health policies. The w o r k of this u n i t w o u l d i n e v i t a b l y involve it in the strategic levels of health care policy, management and planning. It would h a v e, therefore, an overview of both the urban and rural nursing services. At present there are a number of nursing groups and individuals the government may use to seek out nursing opinions on health care. This, h o w e v e r , has the potential to divide the profession's voice, as well as to confuse both the p o l i c y - m a k e r s a n d the p r o f e s s i o n ' s membership on the proper source of nursing policy. In a period of rapid and radical changes in the demand and supply of health care services, we need new policies and strategies to help us achieve our overriding objectives: to p r o v i d e a service to the population and to secure our future in the n e w service m o d e l s . There is no extant model for a national nursing policy unit and the o p t i o n s a v a i l a b l e to us are o p e n to negotiation. CQLLEOIAN VOLUME 2 (1) JAHUSRY1995
34
The major issues facing the profession in the future will focus on the control we exert over our practice and our education programs, the s u p p o r t w e give a n d receive for autonomous practice and the reimbursement of nursing services. New models for service delivery imply different roles, tasks and relationships between nurses, doctors, managers and their clients. These new roles and relationships will only develop if we u n d e r s t a n d the difference b e t w e e n our existing service and that which is required in the future. We must also understand why these changes are required and the impact they will h a v e on our e d u c a t i o n , career structure, practice and place within a national health service. We s h o u l d be t a k i n g s t e p s to set u p a national Nursing Policy Unit - to guide our activities in reviewing our under and postgraduate programs; to build up our regional campuses; to review our recruitment and r e t e n t i o n s t r a t e g i e s ; to d e v e l o p n e w p r a c t i t i o n e r roles; to r e t h i n k o u r career s t r u c t u r e a n d its a p p r o p r i a t e n e s s to the service r e q u i r e d by p o p u l a t i o n s a n d to renegotiate our boundaries with other health and social service occupational groups. If we do not take a proactive approach to the c h a n g e s t h a t are o b v i o u s l y r e q u i r e d to provide future health services, then others will make decisions for us. What's more, they will t a k e these d e c i s i o n s from a p h i l o s o p h i c a l b a s e t h a t is n o t a l w a y s congruent with our own. Nurse managers and clinical practitioners h a v e a role to p l a y in s c r u t i n i s i n g our nursing records to identify the population's d e m a n d s for n u r s i n g care. We m u s t s e r i o u s l y c o n s i d e r w h a t d a t a b a s e s are r e q u i r e d to h e l p us a c c u m u l a t e the information needed to provide good quality nursing care, to measure the outcomes of that care and to cost the nursing services. .
' "„ ROYAL COLLEGE OF NURSING.
We m u s t a l s o r e s e a r c h t h e s u b t l e w a y i n f o r m a t i o n t e c h n o l o g y is s h a p i n g a n d defining n u r s i n g practice. Professionals control technology, but when that technology starts to control the professionals they become technicians. For t h o s e n u r s e s w h o can c o p e w i t h a m b i g u i t y a n d t a k e on t h e c h a l l e n g e of c h a n g e , the c u r r e n t reform of the h e a l t h service offers rich r e w a r d s . N u r s e s w h o c a n n o t accept t h a t the n e w policies will change nursing, who cannot take a proactive approach towards that change, may face the s a m e fate as F l o r e n c e N i g h t i n g a l e a n d become obsolete in their own time. This is a p e r i o d in w h i c h p r a g m a t i c l e a d e r s a r e required, leaders w h o still retain some of their idealism and belief in the contribution nurses can make towards the health of the nation.
For those nurses who can cope with ambiguity and take on the challenge of change> the current reform of the health service offers rich rewards. REFERENCES Burley M and Harvey D 1993 Nurses and their small rural communities: a pilot study in three Gippsland towns. Proceedings of the second national conference, N u r s i n g the country, Deakin University, November:26-28 Commonwealth 1991 The Australian health jigsaw. National health strategy. Issues paper No 1, Canberra, July Commonwealth Department of Health, Housing and Community Services 1993 Remote area nurses inservice educational package. RHSET program 91/92 RH Grant 78, Canberra Commonwealth of Australia 1994 The national rural health strategy, Australian health ministers' conference, March 1994 Coxhead J 1993 United we stand - divided we fall. The Australian Journal of Rural Health, February 1(2):13-18 Department of Health and Community Services (Victoria) 1993 Casemix funding for public hospitals. Melbourne, June Department of Health and Community Services (Victoria) 1993 Future directions for community health and s u p p o r t in Victoria. December Department of Health and Community Services (Victoria) 1994 The report of the review of small rural hospitals. June Gardner H (Ed) 1989 The politics of health. Churchill Livingstone, Melbourne Gardner H (Ed) 1992 Health policy. Churchill Livingstone, Melbourne
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The Kinsey Report 1994 Business investment and regional prosperity: the challenge of rejuvenation. Department of Housing and Regional Development, Canberra, March McMurray A 1993 Country practice: preservation and promise. Proceedings of the second national conference, Nursing the country, Deakin University, November 26-28 Palmer GR and Short SD 1989 Health care and public policy. MacMillan Publishers, Melbourne Sax S 1990 Health care choices and the public purse. Allen and Unwin, Sydney Strasser R 1993 The national conference of rural health training units. The Australian Journal of Rural Health May 1(3): 3-6 The World Bank 1993: World development report: investing in health. Oxford University Press, Oxford
CREDIT TRANSFER ARRANGEMENTS IN NURSING Through the AVCC Credit Transfer Project, the Australian Vice-Chancellors' Committee, with funding assistance from DEET, is developing national credit transfer arrangements in a range of fields of study, in order to assist students transferring b e t w e e n universities or seeking credit in universities for prior study. One of the fields of study in which minimum levels of credit will be piloted in 1995-1996 is nursing. Two pilot schemes have been developed. The first, which w a s implemented in 1994 and will continue in 1995, relates to students w h o have partly completed degree studies in nursing and w h o will be granted minimum credit for these prior studies when admitted to a nursing degree course in another participating Australian u n i v e r s i t y . T h e s e c o n d pilot s c h e m e , to be introduced for the first time in 1995, involves the granting by participating universities of block credit of a m i n i m u m of 2 years in a n u r s i n g degree course for students who have completed a 3-year c o u r s e l e a d i n g to r e g i s t r a t i o n as a Registered Nurse in Australia. The recommendations for the pilot schemes were developed by a Reference G r o u p , chaired by Associate P r o f e s s o r G e n e v i e v e G r a y of t h e Flinders U n i v e r s i t y of South A u s t r a l i a , a n d i n c l u d i n g - in a d d i t i o n to o t h e r u n i v e r s i t y m e m b e r s - representatives of t h e Australian Nursing Council, major employers and TAFE. Details of the pilot schemes, including a list of participating universities, are available from u n i v e r s i t i e s , from s t a t e / t e r r i t o r y university admission centres and from: Dr Anthony P Haydon Director, Credit Transfer Project Australian Vice-Chancellors' Committee PO Box 119, Rundle Mali Adelaide SA 5000 Telephone: (08) 223 1855 Facsimile: (08) 232 6405 E-mail: [email protected].
COLLEGIAN VOLUME 2 (I) JANUARY 1993
INTRODUCTION The federal government's strategy for the r u r a l h e a l t h s e r v i c e , t o g e t h e r w i t h the Victorian government's fiscal policy, will b r i n g r a d i c a l c h a n g e s to h e a l t h service providers and health care workers. Any attempt to redistribute resources immediately challenges the control exerted by powerful groups within the service; in p a r t i c u l a r the m e d i c a l p r o f e s s i o n . The i m p l e m e n t a t i o n of n e w h e a l t h policies, therefore, b r i n g s i n t o p l a y the political p o w e r of the medical profession and its control over the division of labour in health care. In order to discuss the impact of government policy on rural nursing practice the term 'policy' must be defined and the complex p r o c e s s e s i n v o l v e d in formulating government decisions highlighted. Government policies differ not so much in the aims as in the means of pursuing them. The r o u t e from p o l i c y - m a k i n g to implementation is far from linear. Gardner (1989,1992) d i s c u s s e d t h e p o l i t i c a l complexities s u r r o u n d i n g the m a k i n g of health policy and its implementation in the public sector services, and argued that the results are a c o m p r o m i s e by those w i t h vested interests in the outcomes. Health policy, therefore, involves both the politics of, and in, nursing. Discussion on health policy must include nursing policy and its source. Throughout this paper reference is made to the public sector.
HEALTH POLICY The word 'policy' is one that we have all used at some time in our working lives to defend or support some nursing action. We use the word with such carelessness that
others could criticise us for employing it in m u c h the same w a y that a d r u n k uses a l a m p post: m o r e for s u p p o r t t h a n illumination. A simple dictionary definition of the term i n d i c a t e s t h a t policy is a p l a n of action a d o p t e d or p u r s u e d by an i n d i v i d u a l , government, party or business. Palmer and Short (1989) discuss the complex ways in which the term is used to describe different types of statements, intentions and actions associated with the various agencies that make u p a health service. They p r o v i d e examples of the different sources that may be used to determine a government's policy. These sources include: the interpretation of parliamentary speeches; comments made by politicians; the past and present actions, or i n a c t i o n , t a k e n by g o v e r n m e n t , a n d statements made by government about its future intention. The media also play a role in i d e n t i f y i n g , a n a l y s i n g a n d s h a p i n g g o v e r n m e n t policies, not to m e n t i o n the s h a p i n g of the p u b l i c ' s a t t i t u d e s a n d responses to these policies. Policies are s h a p e d by a m u l t i p l i c i t y of socioeconomic and political factors. This is exemplified in the federal g o v e r n m e n t ' s rural health strategy, which identifies the diversity of rural Australia and the health services required to meet the d e m a n d s of local populations throughout the country (Commonwealth 1994). The rural health policies adopted by the federal and state governments are redistributing in nature. They a r g u e for a relocation of resources a w a y from services b a s e d on e x i s t i n g facilities t o w a r d s s e r v i c e s b a s e d on expressed demand. The implementation of this redistributing strategy is a radical change in the allocation
of resources. It challenges traditional models of service d e l i v e r y a n d p o w e r b a s e s , including that of the nursing profession. The rural health strategy's recommendations offer real opportunities to match the supply and demand for health care in rural areas and to promote the role of the advanced n u r s i n g practitioner (Coxhead 1993). The strategy recommends that existing nursing roles in rural and remote areas be formalised and legitimised to ensure a better service for local populations (Commonwealth 1994; DH&CS 1994). Changes of this nature require careful management of change and the education central to achieving the desired outcomes. We m u s t expect t h a t the v a r i o u s p o w e r holders will engage in political activities to either m a i n t a i n the s t a t u s quo or to manipulate a compromise in their favour. Attempts to legitimise the role of the 'Nurse P r a c t i t i o n e r ' will s e r i o u s l y d i s t u r b the
Attempts to legitimise the role of the 'Nurse Practitioner' will seriously disturb the division of labour in health care ... division of labour in health care and the right of the medical profession to control the job c o n t e n t of n u r s e s , a n d they t h e r e f o r e constitute a public challenge by the nursing profession to control its practice and future development. There is a real danger that the medical profession could use its traditional power to convert the 'Nurse Practitioner' role into that of a 'Physician's Aide'. The nursing profession, therefore, must have its policies and strategies in place, to enable it to defend nursing, to take its place at the negotiating table and to ensure that rural nurses can develop as advanced practitioners of nursing. In considering a specific health policy we m u s t a t t e n d to the interrelationship of a number of socioeconomic factors, how these affect the health of the population, and the need for all government sector agencies to consider the effect the outcomes of their policies have on the health of the nation (Sax 1990). Analysis of any government's health policy must take into account its policies for e d u c a t i o n , social s e c u r i t y , h o u s i n g , the environment, trade and industry, and the impact of these on the health of individuals, groups and populations. The rural health
strategy (Commonwealth 1994) draws our attention to the inequalities in health and their linkages to social inequalities based on age, gender, race, occupation and status w i t h i n the social s t r u c t u r e . I n d i v i d u a l s , therefore, have health problems because they are members of a specific community and not because they are individuals. Health services s h o u l d focus on the specific n e e d s of communities rather than on the existence of a p a r t i c u l a r service in a specific location ( C o m m o n w e a l t h 1994; DH&CS 1994). Furthermore, we need to ensure that service models meet the future needs of communities and not the perceptions of specific health care professionals or power brokers. The nursing profession will have to scrutinise its present f r a m e w o r k s for p r a c t i c e b a s e d on individualism if it is to prepare practitioners w h o can meet the n e e d s of p o p u l a t i o n s . The c e n t r a l role of the n u r s e in r u r a l c o m m u n i t i e s is clearly a r t i c u l a t e d by McMurray (1993) when she describes the d i v e r s i t y of the role in t e r m s of social advocacy, counselling, health education and t r a n s p o r t a t i o n c o n s u l t i n g as well as the provision of direct care. McMurray argues for a stop to the standardisation of health care and nursing practice across the country and negates the notion that rural communities must change according to the dictates of urban rationalists (McMurray 1993). It could also be argued that continued definition of the nurse's role as that of an employee of a p a r t i c u l a r service r a t h e r t h a n as a professional is the main source of this need for tight role definitions, job specifications, procedure manuals and the like. One cannot imagine the medical profession debating the definition of its practitioners' roles and the scope of professional practice in this manner. There is a d e a r t h of r e s e a r c h on h e a l t h services in small rural communities. While there are several strategies for rural health services no one a p p e a r s to be willing to define the exact n a t u r e of a ' g o o d ' rural health service. The protocols for health gains in rural areas are still to be written. There is unlimited scope for nursing research into the d e m a n d , s u p p l y and outcomes of health services in rural a r e a s . Most of o u r information on the work of rural nurses is to be found in descriptive journal articles and conference p a p e r s . These s o u r c e s , nevertheless, do provide insights into the challenges to the status quo being mounted by practitioners. This is exemplified by
Burley and Harvey (1993) in their study of three rural Gippsland towns. The study is e m b e d d e d in the c u r r e n t reforms of the health service in Victoria and acknowledges the c h a n g e s t a k i n g p l a c e in t e r m s of downsizing, or closure, of health services in r u r a l c o m m u n i t i e s . Burley a n d H a r v e y (1993) support McMurray's definition of the d i v e r s i t y of the r u r a l n u r s e ' s role a n d consider that this very diversity provides rural nurses with unique insights into the needs of their communities. The researchers a r g u e t h a t it is t h e s e n u r s e s ' b r o a d k n o w l e d g e of their c o m m u n i t i e s w h i c h enables them to practise effectively in the rural setting. The data provided by this study supports the profession's central position: that rural nurses are ideally placed to provide a clear
... rural nurses are ideally placed to provide a clear indication about potential health service delivery options... indication about potential health service delivery options and the value of each to their community. If the V i c t o r i a n g o v e r n m e n t ' s h e a l t h policy is p r o p e r l y implemented, then nurses must be involved in the identification of the p o p u l a t i o n ' s needs for health care and in the formulation of the Health Authority's strategic intents and directions for the rural health service. S u p p o r t for this s t a n c e , a n d for the development of advanced practitioner roles for r u r a l n u r s e s , can be f o u n d o u t s i d e Australia. The 1993 W o r l d D e v e l o p m e n t R e p o r t , 'Investing in Health', focuses mainly on the provision of cost-effective health services worldwide. The r e p o r t c o m m e n t s e x t e n s i v e l y on the cost-effective use of h u m a n r e s o u r c e s a n d d e m o n s t r a t e s the a n o m a l i e s in h e a l t h h u m a n r e s o u r c e utilisation around the world. The World Bank argues in favour of the utilisation of 'Nurse Practitioners' (Coxhead 1993) and highlights the benefits derived in terms of cost-effective services. The challenge for A u s t r a l i a n r u r a l and u r b a n n u r s e s is to m a k e visible their w i d e r p o t e n t i a l
contribution to the cost-effective promotion of the c o u n t r y ' s health. This, h o w e v e r , demands proper utilisation of information technology by practitioners, to quantify and qualify clients' demands for, and outcomes of, nursing care. Similarly, the evaluation of the o u t c o m e s of n u r s i n g care w o u l d be e n h a n c e d by g r e a t e r i n v o l v e m e n t of researchers in quantitative research dealing with the issues surrounding a cost-effective workforce. This was exemplified by one n u r s e m a n a g e r c o l l e a g u e w h e n she complained that our researchers appeared to be f o c u s i n g all t h e i r a t t e n t i o n on peripheral issues rather than providing the d a t a she r e q u i r e d to d e f e n d n u r s i n g in committee. This may be anecdotal evidence, b u t it does merit serious c o n s i d e r a t i o n . H e a l t h care p o l i c i e s b a s e d solely on epidemiological data cannot address these socioeconomic and political variables, or the involvement of a variety resource holder, social groups and service managers in the s u p p l y a n d d e m a n d for h e a l t h care (Commonwealth 1994). Ministers, however, are held to account for the policies they a d o p t a n d t h e d e g r e e to w h i c h their d e p a r t m e n t s scrutinise their policies for h e a l t h c o n s e q u e n c e s . The g o v e r n m e n t departments, therefore, should provide the help and assistance required by regions and health authorities to develop local health care strategic plans tailored to the needs of their c o m m u n i t i e s . G o v e r n m e n t cannot expect local managers to reconstruct their m o d e l s for service delivery w i t h o u t the e d u c a t i o n a l r e s o u r c e s to s u p p o r t the changes required. This draws our attention o n c e m o r e to the p o l i t i c a l a c t i v i t i e s surrounding the new rural health policy and nursing's access to vital resources. NEW POLICIES FOR O L D The N a t i o n a l R u r a l H e a l t h S t r a t e g y (Commonwealth 1994) identifies the need for state and territory health authorities to develop strategic frameworks reflecting the social and economic compositions of their populations, the nature of the population c h a n g e , g e o g r a p h i c l o c a t i o n a n d the d i s t a n c e of t h e c o m m u n i t y from major service centres. The difficulty for nurses in d e t e r m i n i n g the o u t c o m e s of their contributions is the continued inappropriate focus on nursing work in isolation from the i n p u t of o t h e r s . I n s t e a d of an isolated nursing audit we should be focusing on a
clinical audit of a health care team and an a u d i t of t h e c o m p l e t e service to t h e p o p u l a t i o n . This d o e s n o t i m p l y t h a t n u r s i n g a u d i t s d o n o t c o n t r i b u t e to t h e overall audit of the service. The argument is t h a t w e c a n n o t v i e w the i n p u t of o n e professional g r o u p in isolation from the input of other health workers and lay carers. The Rural Health Strategy (Commonwealth 1994) recognises the need for a well-qualified workforce within the rural health services and recommends a review of our existing recruitment of rural students, the contents of under and postgraduate programs in terms of clinical placements in rural areas. The s t r a t e g y also q u e s t i o n s the r e l e v a n c e of urban-based university courses to the actual w o r k u n d e r t a k e n by r u r a l n u r s e s . T h e implementation of the rural health strategy, therefore, demands a radical review of our existing curricula and the selection of clinical
The difficulty for nurses ... is the continued inappropriate focus on nursing work in isolation from the input of others. placements for our undergraduate students. It also raises the question of the status we afford the urban-based education centre over the regional campus. The federal policy for the health of the nation (Commonwealth 1991, 1994; DH&CS 1993) aims to improve the care provided through: ongoing care across services; reductions in hospital lengths of stay; the expansion of outpatient services and home-based care. The latter c h a l l e n g e s our historical a n d i n a c c u r a t e s e p a r a t i o n of h o s p i t a l a n d community-based services. It questions the supremacy of the training hospital as the major source of health care and, in turn, the medical profession's power base as well as n u r s i n g ' s t r a d i t i o n a l career p r o f i l e . F u r t h e r m o r e , this policy s u g g e s t s a relocation of resources from the h o s p i t a l towards the community, with a corresponding redeployment of staff when r e s o u r c e s follow the p a t i e n t i n t o t h e community. The policy, therefore, raises questions about the resources necessary to re-educate hospital nurses for their new roles in the community sector and to renegotiate the established division of work within the nursing profession. ROYAL COLLEGE OF NURSING AUSTRALIA
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The federal g o v e r n m e n t ' s policy for the relocation of resources does not m e a n a reduction in health care resources. It simply suggests that we should relocate those resources a c c o r d i n g to the p o p u l a t i o n ' s e x p r e s s e d d e m a n d s for care. The fiscal policy u n d e r p i n n i n g C a s e m i x d o e s n o t automatically demand reduced resources for the health service. Casemix is only a funding formula and should not be confused with the underlying political decisions regarding total expenditure on the public health service. Casemix may be focused on p a y m e n t for services provided, b u t the DH&CS (1994) a n d the N a t i o n a l Rural H e a l t h S t r a t e g y (Commonwealth 1994) readily acknowledged that there are still problems of a c c u r a t e l y m e a s u r i n g the o u t c o m e s of services provided by hospitals, including the reimbursement of nursing services. Nurses, t h e r e f o r e , m u s t a d d r e s s the i s s u e s s u r r o u n d i n g the o u t c o m e s of n u r s i n g interventions before others do it for them. This in t u r n d e m a n d s our p r o p e r use of information technology to collect, collate and analyse the data we require, to provide costeffective n u r s i n g s e r v i c e s to m e e t a population's expressed demands for nursing care. The DH&CS (1993), in c o m m o n with the federal government, also drew attention to the n e e d for g r e a t e r s c r u t i n y of the m a n a g e m e n t of health care resources. It questioned the traditional models for service delivery and the means of securing the best value for money spent on health services. DH&CS p o l i c i e s d r a w h e a v i l y on the a p p l i c a t i o n of g e n e r a l m a n a g e m e n t principles to the delivery of health services. The advent of managerialism in health care organisations seriously challenges our right to determine our job content and the scope of our professional practice. General managers have the right to determine the division of l a b o u r in their o r g a n i s a t i o n s and to determine the contributions each section of the workforce will make to achieve those managers' operational goals. The longer we define the nurse's role in terms of being an e m p l o y e e of a specific service a n d o n e , therefore, who is closely related to the work of hospital doctors, the more we reinforce the manager's right to define and control the scope of our professional practice. The federal and Victorian state governments h a v e p u r s u e d the goal of cost-effective services by separating the purchaser and p r o v i d e r f u n c t i o n s of the p u b l i c sector jCOLLfiGIAN VOLUME 2 (1) JANUARY 1995
management teams (DH&CS 1993). Thus, the state government's policy emphasises the p r i m a c y of the m a r k e t p l a c e in determining the quality and add-on value of the h e a l t h care p r o d u c t . C o m p e t i t i o n between service providers is viewed as the m o s t effective m e a n s of e n s u r i n g cost containment and increased quality. Service m a n a g e r s are n o t in c o n t r o l of all the variables and cannot, therefore, manipulate the m a r k e t to their a d v a n t a g e . General m a n a g e r s m u s t be able to negotiate any c h a n g e s in the service w i t h the medical profession, which is unlikely to relinquish any of its traditional power and will use its advantage to increase its power base in the new organisation. The major variables out of the m a n a g e r ' s control are medicine's ability to fuel the p u b l i c ' s d e m a n d s for s o p h i s t i c a t e d technological services and the control it
The longer we define the nurse's role in terms of being an employee ... the more we reinforce the manager's right to define and control the scope of our professional practice. exerts over the supply of health services by virtue of the training of doctors. The service managers will have to rely on quality control m e a s u r e s to confine the activities of the m e d i c a l p r o f e s s i o n w i t h i n their p r e s e t b u d g e t s . Similarly, the change t o w a r d s c o m m u n i t y - b a s e d care m a y be n o t h i n g more than the colonisation of the community by the hospital services. This d i l e m m a , c o m p o u n d e d b y t h e c o m p l e x i t i e s of c h a n g e i n h e r e n t in any policy a n d action w h i c h c h a l l e n g e s t r a d i t i o n a l p r a c t i c e s in a b u r e a u c r a t i c organisation, is further complicated by the conservative nature of rural communities. Resistance to change may be encountered not so much on the basis of its relevance to the population's needs for health care but on its break with past behaviours, norms and styles. Unfortunately, nursing will be asked to challenge the status quo from a position of social and organisational weakness, unless o u r r e s e a r c h e r s and p r a c t i t i o n e r s can p r o v i d e our n e g o t i a t o r s w i t h e m p i r i c a l ' h a r d ' d a t a on the cost-effectiveness of clinical practice.
THE IMPLICATIONS FOR RURAL HEALTH SERVICES The N a t i o n a l H e a l t h S t r a t e g y a n d the National Rural Health Strategy (Commonwealth 1991, 1994) highlight the constraints imposed by past fiscal policies on all rural communities and their difficulty in tailoring services to meet their needs. Rural c o m m u n i t i e s often lack the p o p u l a t i o n necessary to secure funding for a mix of hospital, supported residential, community and home care. The National Rural Health Strategy (1994) also draws attention to the inadequate databases required to provide services based on m e a s u r e s of the rural population's health status. Furthermore, the DH&CS (1993) describes the n e w health policy in terms of rewarding hospitals for increased t h r o u g h p u t - treating more patients with lengthy and complex procedures. Thus, not only does the new system differ from the old average b e d / d a y costs system, it also appears to favour the large 'magnet' urban hospital over its rural g e n e r a l i s t c o u n t e r p a r t . Strasser (1994) argues from a medical perspective that the new policy does not serve rural communities well. G i v e n the m e d i c a l p r o f e s s i o n ' s position within the new national rural health unit housed in Moe, Victoria, that profession is in a position to promote and secure its boundaries in rural health care regardless of the impact of the new policy on the health of the nation. I n d e e d , it p r o v i d e s a p r i m e example of the distribution of power and control within the health services. Tn an era of economic recession the rural areas face three major health-related issues: r e d u c t i o n in the size of the p o p u l a t i o n leading to reduced health care resources; the retraction of some hospital-based services i n t o r e g i o n a l c e n t r e s , a n d the n e e d to demonstrate an infrastructure incorporating good health care resources to attract new industries to their regions. This view of a general recession in rural areas is challenged by the Kinsey Report (1992). Kinsey clearly states that, while some rural areas may be experiencing an economic recession, this is not true of all regions throughout Australia. A c c o r d i n g to Kinsey, the available data suggests that the economies of some rural areas are g r o w i n g faster t h a n the major metropolitan areas. The use of Diagnosis-Related Groups as a way of paying for services indicates a major swing away from resource allocation based
on a n t i c i p a t e d care t o w a r d s p a y m e n t for actual care provided. The DH&CS review of small rural hospitals (1994) argues that the redistribution of resources from high cost, u n d e r - u s e d bed-based services t o w a r d s a community-based service will result in a more appropriate, comprehensive and accessible service for rural populations. The resultant closure of beds, however, could be used by those persons resisting change to claim that the real policy is o n e of r e d u c e d p u b l i c spending. The DH&CS (1994) disclaims such arguments by providing examples of 'best practice' in the Macarthur and Lakes Entrance areas of Victoria. The DH&CS claims success for Casemix. This claim is not contested by the federal Minister for Health, Dr Lawrence, w h o h a s a c c u s e d V i c t o r i a ' s M i n i s t e r of Health, Mrs Tehan, of taking all the credit for the new fiscal policy. The federal minister's s u p p o r t for C a s e m i x d o e s i n c l u d e t h e
We may ... see the redeployment of nurses within the rural hospital service and between the hospital and community service, in parallel to similar adjustments in the urban services. statement that a Labour government m a y have pursued the policy differently from the present state g o v e r n m e n t in Victoria (The Australian, T h u r s d a y May 26, 1994:4).
IMPLICATIONS FOR RURAL NURSES There are small clusters of rural hospitals, r e s u l t i n g in a n u n e v e n g e o g r a p h i c a l distribution of resources. The DH&CS (1994) has s u g g e s t e d that in these locations the h o s p i t a l s s h o u l d form a c o n s o r t i u m to p r o v i d e an i n t e g r a t e d service in w h i c h hospital beds are located in larger centres. T h u s , the policy a p p e a r s to s u p p o r t t h e formation of regional centres. This will have a d i r e c t i m p a c t on the e m p l o y m e n t a n d distribution of nurses. We may, therefore, see the redeployment of nurses within the rural hospital service and between the hospital and c o m m u n i t y service, in parallel to similar a d j u s t m e n t s in the u r b a n services. T h e concept of multiskilling in nursing practice may involve not only the extension of nursing
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practice into other health workers' areas of practice but also the ability to move between hospital and community settings and between the different 'specialist' clinical areas. We m a y even w i t n e s s a r e d e f i n i t i o n of the d i v i s i o n of l a b o u r in h e a l t h a n d the emergence of new health care occupational groups. There is a distinct possibility that n u r s i n g will be d r a w n closer to m e d i c a l practice and that direct care-giving activities will be carried out by vocationally-trained support workers. Thus the organisational strategies developed in the hospitals of the m i d - 1 9 t h c e n t u r y will be a d a p t e d a n d p e r p e t u a t e d w e l l into the 21st c e n t u r y . Rural and remote area health services have recruitment and retention problems (DH&CS 1994). Rural n u r s e s m a y be tied to their employment base through family commitments and are not free to relocate to n e w areas of e m p l o y m e n t . F u r t h e r m o r e , rural women often have to contribute to the w o r k on their families' farms and this is reflected in their work patterns. The service may require a relocation of resources, but its major r e s o u r c e m a y be tied to a specific location and pattern of shift work. Thus, new r e c r u i t m e n t a n d r e t e n t i o n policies are required. Managers will have to create new a n d a t t r a c t i v e n u r s i n g jobs to entice e x p e r i e n c e d n u r s e s to fresh l o c a t i o n s . The creation of the Rural Health S u p p o r t Education and Training (RHSET) program by the federal Minister for Health, Housing and C o m m u n i t y Services has opened u p new opportunities for nurse educationists and r e s e a r c h e r s to i m p l e m e n t c h a n g e in the practice of rural n u r s e s ( C o m m o n w e a l t h 1994). The establishment of medical Rural Health Training Units in several states, and the National Rural Health Unit in Victoria, has given new impetus to the establishment of multidisciplinary Rural Health Training Units (National Rural Health Strategy 1994). These Rural Health Units, however, were established mainly to recruit doctors to rural areas. A great deal of work will need to be carried out to convince the nursing profession t h a t t h e r e are s t r a t e g i c benefits for p r a c t i t i o n e r s in b e i n g d r a w n into a ' m u l t i d i s c i p l i n a r y ' u n i t d o m i n a t e d by medicine. The c r e a t i o n of a ' m u l t i disciplinary' unit under the auspices of the rural health strategy (DH&CS 1994) could simply provide the medical profession with yet another base from which to maintain its p o w e r a n d c o n t r o l over the d i v i s i o n of
COLLEGIAN VOLUME 2 fl) JANUARY 1995 ,
labour in health care. If this were to happen, then there would be no advantage to the nursing profession in joining such a unit; nor would we expect to see any changes in the i l l n e s s - o r i e n t a t e d h e a l t h services of the present. The success or failure of the new health policy lies in the DH&CS political will to challenge the traditional orthodoxy of the health services that 'doctor knows best'. The nursing profession does have an opportunity to hold the balance of power in this political tussle and to secure its place in the future service.
CONCLUSION The reforms of the rural health services draw our attention to the f u n d a m e n t a l issues facing governments throughout the world: the d i s t r i b u t i o n of h e a l t h r e s o u r c e s according to the population's needs and the delivery of cost-effective services. The role and place of nursing within these strategies is clearly identified as a major resource and one that is not being utilised to its maximum potential. We cannot ignore the impact of the political e c o n o m y of h e a l t h on our control over our future roles and remits.
A NURSING POLICY UNIT The wide range of changes implicit in the strategies for health set out at both federal and state levels of g o v e r n m e n t p r e s e n t s strong arguments in favour of creating a Nursing Policy Unit. This agency would be actively involved in the formulation of all
... work will need to be carried out to convince the nursing profession that there are strategic benefits for practitioners in being drawn into a fmultidisciplinaryf unit dominated by medicine. nursing policy, in researching the outcomes of present policy and in acting as a source of advice for those formulating health policies. The w o r k of this u n i t w o u l d i n e v i t a b l y involve it in the strategic levels of health care policy, management and planning. It would h a v e, therefore, an overview of both the urban and rural nursing services. At present there are a number of nursing groups and individuals the government may use to seek out nursing opinions on health care. This, h o w e v e r , has the potential to divide the profession's voice, as well as to confuse both the p o l i c y - m a k e r s a n d the p r o f e s s i o n ' s membership on the proper source of nursing policy. In a period of rapid and radical changes in the demand and supply of health care services, we need new policies and strategies to help us achieve our overriding objectives: to p r o v i d e a service to the population and to secure our future in the n e w service m o d e l s . There is no extant model for a national nursing policy unit and the o p t i o n s a v a i l a b l e to us are o p e n to negotiation. CQLLEOIAN VOLUME 2 (1) JAHUSRY1995
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The major issues facing the profession in the future will focus on the control we exert over our practice and our education programs, the s u p p o r t w e give a n d receive for autonomous practice and the reimbursement of nursing services. New models for service delivery imply different roles, tasks and relationships between nurses, doctors, managers and their clients. These new roles and relationships will only develop if we u n d e r s t a n d the difference b e t w e e n our existing service and that which is required in the future. We must also understand why these changes are required and the impact they will h a v e on our e d u c a t i o n , career structure, practice and place within a national health service. We s h o u l d be t a k i n g s t e p s to set u p a national Nursing Policy Unit - to guide our activities in reviewing our under and postgraduate programs; to build up our regional campuses; to review our recruitment and r e t e n t i o n s t r a t e g i e s ; to d e v e l o p n e w p r a c t i t i o n e r roles; to r e t h i n k o u r career s t r u c t u r e a n d its a p p r o p r i a t e n e s s to the service r e q u i r e d by p o p u l a t i o n s a n d to renegotiate our boundaries with other health and social service occupational groups. If we do not take a proactive approach to the c h a n g e s t h a t are o b v i o u s l y r e q u i r e d to provide future health services, then others will make decisions for us. What's more, they will t a k e these d e c i s i o n s from a p h i l o s o p h i c a l b a s e t h a t is n o t a l w a y s congruent with our own. Nurse managers and clinical practitioners h a v e a role to p l a y in s c r u t i n i s i n g our nursing records to identify the population's d e m a n d s for n u r s i n g care. We m u s t s e r i o u s l y c o n s i d e r w h a t d a t a b a s e s are r e q u i r e d to h e l p us a c c u m u l a t e the information needed to provide good quality nursing care, to measure the outcomes of that care and to cost the nursing services. .
' "„ ROYAL COLLEGE OF NURSING.
We m u s t a l s o r e s e a r c h t h e s u b t l e w a y i n f o r m a t i o n t e c h n o l o g y is s h a p i n g a n d defining n u r s i n g practice. Professionals control technology, but when that technology starts to control the professionals they become technicians. For t h o s e n u r s e s w h o can c o p e w i t h a m b i g u i t y a n d t a k e on t h e c h a l l e n g e of c h a n g e , the c u r r e n t reform of the h e a l t h service offers rich r e w a r d s . N u r s e s w h o c a n n o t accept t h a t the n e w policies will change nursing, who cannot take a proactive approach towards that change, may face the s a m e fate as F l o r e n c e N i g h t i n g a l e a n d become obsolete in their own time. This is a p e r i o d in w h i c h p r a g m a t i c l e a d e r s a r e required, leaders w h o still retain some of their idealism and belief in the contribution nurses can make towards the health of the nation.
For those nurses who can cope with ambiguity and take on the challenge of change> the current reform of the health service offers rich rewards. REFERENCES Burley M and Harvey D 1993 Nurses and their small rural communities: a pilot study in three Gippsland towns. Proceedings of the second national conference, N u r s i n g the country, Deakin University, November:26-28 Commonwealth 1991 The Australian health jigsaw. National health strategy. Issues paper No 1, Canberra, July Commonwealth Department of Health, Housing and Community Services 1993 Remote area nurses inservice educational package. RHSET program 91/92 RH Grant 78, Canberra Commonwealth of Australia 1994 The national rural health strategy, Australian health ministers' conference, March 1994 Coxhead J 1993 United we stand - divided we fall. The Australian Journal of Rural Health, February 1(2):13-18 Department of Health and Community Services (Victoria) 1993 Casemix funding for public hospitals. Melbourne, June Department of Health and Community Services (Victoria) 1993 Future directions for community health and s u p p o r t in Victoria. December Department of Health and Community Services (Victoria) 1994 The report of the review of small rural hospitals. June Gardner H (Ed) 1989 The politics of health. Churchill Livingstone, Melbourne Gardner H (Ed) 1992 Health policy. Churchill Livingstone, Melbourne
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The Kinsey Report 1994 Business investment and regional prosperity: the challenge of rejuvenation. Department of Housing and Regional Development, Canberra, March McMurray A 1993 Country practice: preservation and promise. Proceedings of the second national conference, Nursing the country, Deakin University, November 26-28 Palmer GR and Short SD 1989 Health care and public policy. MacMillan Publishers, Melbourne Sax S 1990 Health care choices and the public purse. Allen and Unwin, Sydney Strasser R 1993 The national conference of rural health training units. The Australian Journal of Rural Health May 1(3): 3-6 The World Bank 1993: World development report: investing in health. Oxford University Press, Oxford
CREDIT TRANSFER ARRANGEMENTS IN NURSING Through the AVCC Credit Transfer Project, the Australian Vice-Chancellors' Committee, with funding assistance from DEET, is developing national credit transfer arrangements in a range of fields of study, in order to assist students transferring b e t w e e n universities or seeking credit in universities for prior study. One of the fields of study in which minimum levels of credit will be piloted in 1995-1996 is nursing. Two pilot schemes have been developed. The first, which w a s implemented in 1994 and will continue in 1995, relates to students w h o have partly completed degree studies in nursing and w h o will be granted minimum credit for these prior studies when admitted to a nursing degree course in another participating Australian u n i v e r s i t y . T h e s e c o n d pilot s c h e m e , to be introduced for the first time in 1995, involves the granting by participating universities of block credit of a m i n i m u m of 2 years in a n u r s i n g degree course for students who have completed a 3-year c o u r s e l e a d i n g to r e g i s t r a t i o n as a Registered Nurse in Australia. The recommendations for the pilot schemes were developed by a Reference G r o u p , chaired by Associate P r o f e s s o r G e n e v i e v e G r a y of t h e Flinders U n i v e r s i t y of South A u s t r a l i a , a n d i n c l u d i n g - in a d d i t i o n to o t h e r u n i v e r s i t y m e m b e r s - representatives of t h e Australian Nursing Council, major employers and TAFE. Details of the pilot schemes, including a list of participating universities, are available from u n i v e r s i t i e s , from s t a t e / t e r r i t o r y university admission centres and from: Dr Anthony P Haydon Director, Credit Transfer Project Australian Vice-Chancellors' Committee PO Box 119, Rundle Mali Adelaide SA 5000 Telephone: (08) 223 1855 Facsimile: (08) 232 6405 E-mail: [email protected].
COLLEGIAN VOLUME 2 (I) JANUARY 1993