National Rural Health AllianceNRHA
Continuing Professional Education for Rural Practice
Judith Cornell Executive Director
New South Wales College of Nursing
1st National Rural Health Conference Toowoomba 14th - 16th February 1991
Proceedings
Continuing Professional Education for Rural Practice
Judith A. Cornell Executive Director
New South Wales College of Nursing
This paper looks at the educational needs of health care professionals, particularly nurses, from both a service delivery and professional development view. It examines some of the issues involved, reviews the current situation in NSW and poses some strategies that may be used in the development of an overall national strategy.
The issues relating to continuing professional education for nurses and nursing have been the subject for debate for many years as they have been for heahh professionals across all disciplines.
Continuing profession education falls into two categories:
l Education related to service needs and delivery
l Professional development of individuals.
Following an intense period of review the Nursing Education Targets 1989-2000 document was produced and has become the reference point for those involved with nurse education.
1 quote from the section dealing with Non Award (Continuing)NursingEducation Programs.
In accordance with the Australian Government’s proposals in Higher education a policy statement, (1988), non-award (continuing) education for nurses is viewed as being the combined responsibility of employers in both public and private sectors, nursing faculties in education institutions, and professional nursing organisations.
The nursing profession acknowledges that it is neither desirable nor practicable to expect that all nurse education programs will be provided through the higher education sector and via formal award courses. However, it is essential that, especially in relation to the development of specialised knowledge and skill, there is an organised and continuous system of ongoing nurse education for (a) meeting workforce demands, (b) maintaining professional standards, and (c) ensuring staff retention and job satisfaction. Furthermore, the levels and standard of non-award nurse education must be valued by, and be able to provide ongoing benefits to, the community as well as the individual nurse and the profession; for example, cost effectiveness in terms of transfer of credits to formal award programs conducted in the higher education sector.’
The problems related to Continuing Professional Education in rural areas are compounded by geography, resource availability and peer support that results in a “professional isolation”
requiring specific needs analysis.
The problem of geography may be overcome by any of the distance education modalities, however you are still left with the resource and peer support issues. I referred earlier to education related to the service needs and delivery area as being distinct from professional development and I will spend a few minutes expanding on the specific issues related to both service needs/delivery.
Health care in rural settings is delivered by professionals working in a variety of ways that include private practice, hospitals, community agencies and outreach programs to name but a few. One of the particular features is that funding and priorities alter, often with bewildering speed, thus requiring the health professionals to change their working patterns.
Nurses are particularly vulnerable to such changes with a resultant blurring of their role boundaries. The decision of a Government to alter the role of a rural or referral hospital may mean that nurses are required to provide a service in an area in which they have not previously practiced.
One of the examples I am most directly invovled in currently is the oncology and palliative care area. The preparation, administration and subsequent disposal of cytotoxix agents is but one of the educational deficits recently identified. The demand for education in this area is directly related to an alteration in service delivery patterns. Preparation for beginning practice and support of the neophyte or novice is of particular concern. The availability of an experienced preceptor or mentor will depend on location and the beginning practitioner’s ability to identify an appropriate person to act for him.
Nurses, (and I suspect other health professionals) who gain their education and early clinical experience in larger centres and the cities are often ill equipped to fulfil the multi dimensional role required of rural practice. The “specialisation” of clinical practice makes it very difficult to gain experience in the variety of areas that one needs. The divisional structures found in the city hospitals separates medicine from surgery from obstetrics and gynaecology and so on and whilst the basic educational preparation of the nurses is comprehensive in nature, it is difficult to develop the more specialised knowledge that will allow the advanced practice of nursing that is so important in isolated communities.
Professional Development
Quite apart from the service delivery and preparation for practice issues there are the professional development needs of practitioners. These areas may be professional discipline related rather than the day to day issues of their practice. Career development and mobility may well be influenced by the availability of education and staff development. Such development may be lateral and not necessarily linear specific. Mobility will be influenced by several factors, the availability of a position, the need to move location due to a partneri-js transfer or a personal desire to alter career direction.
Career planning in its broadest sense is often influenced by a variety of external and internal factors not the least of which is educational availability of a suitable nature. The 1989 study undertaken by Hines?, clearly outlines the variety of educational deficits perceived by nurses either in relation to themselves or others and recommends that a
. prioritised grid of learner demands be used to identify priorities for courses in relationship to overall needs and their applicability across a variety of demographic groups.3
The 1988 AHMAC recommendations in relation to Continuing Education for Primary Health Care in Australia4 summarised the barriers to educational access as including:
l lack of employer support
l central location and inflexible timetabling
l fixed entry criteria for courses 0 cost
0 replacement staff
l lack of information
all of which are issues that require resolution. The same report identified the type of non- award courses that are required.
The programs should
l relate to a specific issue or problem of significance to the practitioner;
l provide opportunities for application or practice of new knowledge and skills; and
l provide opportunities for peer support sharing of experiences and the development of networks.’
It is interesting to note that all of the literature relating to Continuing Professional Education issues has much the same focus and direction - what of course rremains is the will 0 of employers
l practitioners themselves
l professional organisations; and
l educational institutions
to ensure that the recommendations made are advanced further.
It seems that we all know what the problem is - what we are having difficulty with is the solutions.
The next section of my discussion will focus on some of the issues that have been identified and the difficulties inherent in their resolution, clearly there is no one simple solution to continuing professional education !
The Issues
I. Geographical Isolation can only be overcome by ensuring that the education is taken by the practitioner in the most suitable mode (or acombination of modes). The problems of staff release arc recognised, firstly a suitable replacement must be found for the practitioner or the service is left unmanned, and secondly, tlhe person concerned may have difficulty in arranging to be away from their home for any period. Dependent children or family members may create a problem, so too does personal cost. Both issues arc equally difficult to resolve.
On the other hand taking the program to the participant on a on’e to one/face to face basis becomes very costly. Not only do you have to find a qualified and experienced teacher or facilitator who can be released from their workplace, the travel and accomodation costs must be added to the salary replacement costs. The availability of an appropriate facilitator may well be influenced by the same factors as the rural practitioner.
In the case of a professional organisation providing education, it simply is not viable to send one person to provide classroom teaching for cxtendcd periods. There is a need to ensure cost effectiveness of all educational offerings. In addition the requirement to meet the diverse needs of the rural practitioner often means that more that one person is required.
2. Funding issues must be resolved. It is my belief that considerable disparity exists between professional groups and the regions and areas. As an example, in New South Wales the State is divided into health regions and in relation to nursing there is noticeable difference in funding availability. I am cynical enough to suggest that this appears to be related to the recruitment and retention issues rather that the educational needs. The ability of regions to negotiate funding for special educational initiatives would seem to be personality driven.
3. Educational Resource Support The availability of reference material, access to libraries with professional collections and qualified teaching support is v,ariable and in many ways linked to the individual’s knowledge and initiative.
There is little point in undertaking a course in the distance mode unless there is access to resource material. Some programs recognise the problem of access and provide comprehensive support in the way of printed resource booklets, however, the problem of copyright, reproduction and the resultant increase in costs recluires considerably more discussion.
4. Communications/Appropriateness of Programs. Isolated rural practitioners have limited access to the information provided regarding the availability of programs and it seems that very often they choose a program because they know about it and it seems to be the only choice available. This in turn leads to their attendance in inappropriate programs on the basis that “something is better than nothing”.
Advertising by professional associations tends to be confined to circulation of their own membership or by word of mouth. Professional journals, ma,gazines and newsletters contain incomplete information on an ad hoc basis and a regional staff development department advertising material may not always reach the appropriate consumer. Those who work outside the Department of Health structure would not. necessarily have access to the latter.
One further problem that should be referred to is related to the timeliness of information.
Those who work in the truly remote areas do not receive mail deliveries on a regular basis, newspapers may be IO-12 days old before they are received. Tight time frames for applications can prove to be unrealistic for that group of worker. Mail deliveries also create problems for those who are required to meet assignment submission timetables thus effectively shortening their preparation time.
The Current Situation in New South Wales is confused for all of the reasons I have already alluded to.
Continuing Professional Education is offered by:
l The professional organisations which include amongst others, the New South Wales College of Nursing, Royal College of Nursing, Australia, Australian College of Health Service Executives, Royal Australian College of General Practitioners, New South Wales Nurses’ Association.
. Employers at local level according to their service priorities,
l The Department of Health (NSW) offers courses for nurses via the NSW College of Nursing. The course specifically offered for nurses in rural areas is Clinical Nursing Studies and is of 12 weeks duration offered as 6 two week bloclks. Three courses a year in various country centres are funded by the Department of Health. One of the three
courses is always held at Dubbo and is intended to meet the needs of nurses in the Orana and Far West Health Region. The course consists of core studies and allows the nurse to negotiate to meet his/her specific workplace and/or specialty needs.
l The tertiary sectorprovidesnon-awardcoursesvia their continuing education departments.
It is more usual for these courses to be offered in the distance: education mode although there are some instances of other modes being made available.
It is fair to say that there is no consistant approach being taken in New South Wales, each offering is made available according to the constraints of the sponsoring organisation and the funding availability. Consultation between the providors is on an informal level and tends to be occupation specific, the opportunities for multi-disciplinary education are very limited and tend to be confined to conferences of a general natulre.
The Nursing Branch of the Department of Health (NSW) is currently putting together a directory of all post registration and post enrollment award and non-award courses for nusres and as the Chief Nursing Officer remarked to me last week has opened “Pandora’s Box” - there is no consistency of definition, content or approach! Regrettably, time precluded an analysis of the offerings in other States and Territories although anecdotal evidence suggests that the situation is as equally confused as New South Wales.
What then are the Solutions?
The Draft National Rural Health Strategy document that has been circulated for discussion at this conference posts some solutions to resolve the problems, howcvcr I believe that it is important to differentiate the strategies for undergraduate, post graduate and continuing professional education.
As1 have described earlier there are numerous direct and indirect providors in the continuing professional education category.
The problems of continuing professional education for all health care workers have been the subject of several reports, although to bc fair it should be said that I am more familiar with those pertaining to the nursing profession. It is my belief that the most urgent priority lies in the arca of the current availability of programs. There are numerous direct and indirect providors, all of whom market to a specific group and there is an urgent need for a co- ordinated approach to identify:
l providors
0 available programs
l quality (length and depth, accreditation, and cross course credits)
l mode of available programs 0 costs.
Such an analysis and listing would do much to assist in identifying the “gaps” that exist in educational offerings. Following compilation of the material, it should then bc possible to develop specific strategy in relation to:
. distribution of programs
l future development
l funding mechanisms
l the riced to provide adequate relief for attendance
. delivery methods (face to face, distance, teleconferencing, or utilisation of other appropriate technology).
A co-ordinated national approach to continuing professional education will ensure that the educational needs of the rural health worker is met as well as the overall health care needs of the rural communities they serve. Such an approach will also ensure the effective use of resources by avoiding wasteful duplication of material.
In conclusion, it can be seen that whilst there are currently a number of various options available, the ad hoc approach hinders the development of a consistant national strategy.
References
1. Nursing Education Targets 1989 - 2000. Proceedings of the Nursing Education Targets Project, April 1990. ISBN O-909 449-42-2
2. Hines, J. A Study of the Continuing Education Needs of Registered and Enrolled Nurses in N.S.W. School of Nursing and Health Administration, Charles Sturt University - Mitchell. November, 1989.
3. ibid, p. 11.
4. Australian Health Ministers Advisory Council. Continuing Education for Primary Health Care in Australia: Summary Report and Recommendations. 1988. ISBN 0 7243 4020 3
5. ibid, p. 7.
