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The role of the registered nurse in the rural but not remote, setting

Frank Evans

The Australian Journal of Rural Health © Volume 2 Number 2, November 1994

T he role of the registered nurse in the rural, but not remote, setting BY FRANK EVANS

ABSTRACT: The perceived limited use of extended training by the majority of registered-nurses (RI%) employed in a42-bed rural, but not remote, hospital withan established program of advanced training far RNs, #as the motivation to conduct a fwmal study into their use. The purpose of the : study was to evaluate the effectiveness.of the. program in terms of utilisation, financial benefits, professional appropriateness.and structural efficiency.. KEY WORDS: Registered nurse, extended skiIls, advanced training, rural, role

INTRODUCTION

The extended role of the registered nurse (RN) in remote areas is well established and accepted by most health professionals as necessary, if adequate health services are to be provided to those living there. This acceptance does not appear to have ‘flowed on’ to their less remote, rural colleagues.

The medical, allied health and nursing literature written during the last five years suggests there is little research relating to the extended role of the RN in Australia. In contrast, British journals have been reporting progress on the debate for some years. - 1,‘,3,4s,6 This discussion has centred around such issues as:

what constitutes an extended role;

who should decide what procedures nurses are capable of and should be performing;

what level of training and certification is necessary;

what benefits are inherent in such role extensions.

Frank Evans is Health Service Manager of Narrabri and Boggabri Health Services. He has a Bachelor of Health Science (Nursing) degree, is a registered nurse, certiliedmidwife and holds a Clinical Nursing Studies Certificate. He has worked clinically in remote areas where his cannulation, suturing and advanced life support skills were used daily.

Derrick’ describes an extended role as one that is not taught during basic training. However, this definition is unqualified as Ward’ quite rightly points out that ‘one of the hallmarks of professional practice is the ability and willingness to learn new skills’. He further asserts that the traditional role of the RN must be identified in order to ascertain the extended role. Rundell agrees with the latter view, suggesting that it is highly debatable what constitutes an extended role, though he is quite clear about what an extended role is not, that is,

the delegation of minor medical chores to registered nurses, eager for status. For the purpose of the present study, an extended role was taken to be one that had not traditionally been performed by registered nurses employed in a hospital without some form of extra training and certification.

Australia, like Britain, has no standardised accreditation process for RNs practising extended skills. In 1992, the United Kingdom Central Council’ issued a document titled The scope of professional pracrice which replaced the require- ment for certification by health authorities with a set of principles placing the responsibility for competence firmly with the individual nurse. This is consistent with Thomas? who believed that we should no longer think in terms of extending our roles as nurses, rather we should think in terms of role development.

Ward’ questions whether nurses should decide what roles they undertake, or whether the medical profession should do this. Such questions have

16 The Australian Journal of Rural Health

some validity due to the increasing number of tasks and procedures being performed by nurses that were traditionally a medical responsibility. This is by no means new: such tasks as taking blood pressures were once placed firmly within the responsibility of the medical profession.

The Royal College of Nursing in 1978l stressed the need for joint discussions, as well as mutual trust and respect between professions, when determining appropriate role extensions for registered nurses. They also argued the need for the extended role to be in the patients’ interests. Whilst few would argue against the patients’ interests being foremost, it is possible that this may represent a somewhat narrow perspective on health care, given that health services and therefore the health professionals they employ, also have a responsibility to the communities they service.

This responsibility requires them to provide the most appropriate health services, at the highest possible level, utilising the minimum necessary financial resources. Employing a visiting medical officer (VMO) to attend to a patient after hours

to perform a relatively simple task, such as resiting an intravenous cannula, or adding a medication to an intravenous flask of fluid, for example, would not appear to represent the most efficient use of resources and therefore not represent maximum benefit to the community. Perhaps it can be argued that health professionals of whatever ilk should ensure they are utilised in a manner that best services their communities. This means that tasks that may be performed by either nurses or medical officers should be allocated on the most cost- effective basis.

BACKGROUND

A study was conducted in a 42-bed rural, but not remote, hospital in New South Wales, approxi- mately 200 kms from the nearest base hospital. The hospital provides acute obstetric, medical, surgical and slow stream rehabilitation services to a population of approximately 9 000. The nurses employed at the hospital in this study were required to complete a theoretical and a clinical module,

including five supervised clinical trials for each extended skill, prior to being ‘accredited’. The program was voluntary and was developed and managed by the local nurse educator. This appears to be accepted practice in rural New South Wales

at least, where extended skills are usually only practised by RNs who have been accredited by the health service by which they are employed. Whilst the lack of uniformity in certification throughout the nursing profession in Australia is currently a problem, local health service certifica- tion should offer some protection, should a specific nurse’s practice be questioned or challenged legally.

The perceived limited use of extended training by the majority of RNs employed at the hospital was the motivation to conduct a formal study into their use. The purpose of the study was to evaluate the effectiveness of the program in terms of utilisation, financial benefits, professional appro- priateness and structural efficiency.

The extended skills program for RNs began at the hospital in this study in May 199 1 and included four skills: intravenous cannulation, adding medications to intravenous (IV) flasks, simple suturing and defibrillation. Of the 29 RNs eligible to participate in the program, only 13 are accredited to perform an extended skill. Two nurses are accredited to insert intravenous cannulae, 10 are permitted to load intravenous flasks with an additive drug and one is accredited to defibrillate. No nurses are currently accredited with more than

one extended skill.

METHOD

Nursing staff were asked to record details relating to the performance of tasks under the extended skill program. Information was collected over one month during a period of ‘relatively normal’ levels of activity. Data collection forms asked for the time, date, practitioner’s name and status (VMO or RN) and a description of the task performed. The forms were placed at the nurses’ stations in the two inpatient areas and in the accident and emergency department. All nursing staff were requested to participate in data collection.

RESULTS AND DISCUSSION

The records identified 34 occasions on which intra- venous cannulae were inserted and nine occasions

where simple suturing was performed. No records of defibrillation were returned. Thus, during the study, 43 tasks were performed that were an accreditable skill for RNs working at this hospital. Of those 43, only four were performed by RNs.

Volume 2, Number 2 - February 1994 17

This means that in many instances, these tasks could have been performed by RNs, if they had completed the appropriate accredited skills training. The breakdown of skills performed by which professional group is summarised in Figure 1.

The data relating to the skills that were per- formed at times other than when the VMOs were in the hospital for their routine rounds is interesting. Thirty-three of the tasks performed by VMOs were performed at times other than during routine rounds

(see Figure 2). However, the data do not differentiate between

special visits by VMOs nor tasks performed at the time of admission to hospital. The lack of data relating to the adding of medications to intravenous flasks was disappointing as the majority of nurses accredited with an extended skill are accredited with this very one.

The success of this study relied on the partici- pation of all nursing staff to identify tasks that were performed and to record them appropriately. The results suggest that no intravenous flasks of fluid had medications added to them by either VMOs or RNs during the period of the study.

Figure 1 - Frequency of skills by profession

Extended skills program Accreditable skills

Frequency performed

40 /

Simple sut!xiIlg

IV flask additives

Defibrillation

However, it is doubtful that this claim is accurate. It is therefore likely that a number of relevant tasks were simpy not recorded.

Overall, the standard of data collection during this study was disappointing. The absence of data relating to intravenous additives suggests that a significant number of tasks relevant to this study were not recorded. Nonetheless, the percentage of tasks recorded that were performed by VMOs suggests that the program of skills training at this hospital has not been wholly successful. The resources required to run such a program are significant and as such, the program needs to result in real benefits for patients, the health service and the community. The apparent lack of commitment by some RNs to collect data may be an indication of their general lack of interest in attaining extended skills, or reflect some other factor. However, the data do suggest an unsatisfactory trend, that is, VMOs charging the health service for activities RNs could do. It is worth noting that the cost to the health service for a VMO to insert an intraven- ous cannula during the night is $122.00 if a special visit is required. If this task were performed by a

Figure 2 - Type of visit required by VMO

Extended skills program Accreditable skills

Accreditable Skills

n TOTAL 3 MEDICAL OFFICERS H REGISTERED hWRSES

18 The Australian Journal of Rural Health

RN on duty, it would represent an equivalent saving to the health service and hence the community it is servicing.

It is for this reason that a more focused approach to the program is recommended. Key nursing personnel, such as night duty staff, nursing unit managers and senior nurses, who are frequently in charge of the hospital after hours, will be encouraged to acquire the necessary skills and knowledge to insert an intravenous cannula. It will also be recommended that adding medications to an IV flask of fluid be accepted as part of the RNs’ ‘normal role’, with education relating to this task to become a routine part of the RNs’ orientation

program. Discontinuation of the simple suturing and defibrillation component of the program may

represent a more efficient use of resources, as resources not utilised could be directed to more productive areas.

CONCLUSION

It is a challenge for all rural health services, and hence rural health professionals, to provide the

maximum and most appropriate health services at the highest possible level to their communities. To do this, the outcome of services must be compared to their associated costs. Decisions relating to levels of professional practice can no

longer be made in isolation, as decisions based solely on what is best for nursing and nurses or what is best for the medical profession and doctors, may not be what is best for the patients nor for the communities in which they live. It is also no longer sufficient to base practice solely on what is best just for specific patients, as our customers are the entire community we service. We have an obligation to maximise the level of health of our community and to prevent individuals from becoming patients. The role of the RN can have a significant impact on the services that can be provided by rural health practitioners, as resources saved through the appropriate use of skills can facilitate the delivery of health services that would not otherwise be provided.

REFERENCES

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Derrick S. What are the legal implications of extending

nursingroles. TheProfessional Nurse 1989;4(7):35&352.

Ward R. The extended role of the nurse: A review. Nursing

Standard 1991;6(11):33-36. Hand D. Taking a giant leap towards freedom. Nursing

Standard 1992;6(42):23.

Rundell S. Expanding boundaries. Nursing Times;87

(8):22.

Walsh M, Clarke L. Is the extended role component of nursing redundant? Nursing Standard 1989;3(48):42-43.

Alderman C. Weathering the storm. Nursing Standard

1992;6(43):22-23