INTRODUCTION

Australian remote area nurses (RANs) are specialist advanced practice nurses. They work in unique, challenging and sometimes dangerous environments to provide a diverse range of healthcare services to remote and predominantly Aboriginal communities. There is an emerging skills gap in the remote nursing workforce as experienced and qualified RANs leave this demanding practice. There is a shortage of new nurses interested in working in these areas, and many of those who enter remote practice leave after a short time. Distance management was examined in order to gain a better understanding of its effects on the retention of RANs in the Australian states of Northern Territory (NT), Western Australia (WA) and South Australia (SA). Distance management in this context occurs when the health service's line management team is located geographically distant from the workplace they are managing.

METHODS

The study used a mixed method design, with a combination of anonymous surveys and interviews conducted by telephone and face to face. Qualitative and quantitative data were collected. The data were thematically analysed and basic descriptive statistics were also used. All RANs who worked in government and other non-Aboriginal controlled remote health services in NT, SA and WA were included in the sample. Sixty-one RANs (anonymous survey, 55% response rate) and 26 ex-RANs (telephone interview) participated in the research. The ex-RANs were sampled using a snowball technique where interviewees recommended former colleagues for interview. Nine nursing executives with expertise in distance management of remote health services also contributed (face-to-face interview), and they are referred to as 'the experts'.

RESULTS

Respondents expressed a dichotomy in their reactions to remote area nursing. On one hand, they expressed a strong sense of pleasure and satisfaction in the nature of their work; while, on the other, they expressed dissatisfaction with aspects of infrastructure, support and management practices. Positive aspects included autonomy of practice, working in a small team, cross-cultural practice, and the beauty and isolation of the setting. Negative aspects included poor orientation, high stress, inadequate resources, poor systems, unrealistic expectations from communities and managers leading to excessive workload, and perceived lack of support from management. The greatest negative issue raised was poor handling of leave replacement, where RANs on leave were not replaced with appropriately qualified and skilled nurses. Respondents noted a frequent change in managers, and reported that the lack of stability in management contributed to lack of support for both RANs and their managers. Lack of support from managers was frequently cited as a main cause for ex-RANs leaving their employment. Despite this, almost all respondents indicated a willingness to remain in the remote workforce if possible. Experts noted that where management was dysfunctional, RAN retention rates fell. They also acknowledged the need for good communication, interpersonal skills, availability of staff development, leave, relief staff, feedback, debriefing, professional support and working conditions. Experts believed managers should make use of available and emerging technology to communicate with RANs, and work to improve RANs' understanding of the role of the management team.

CONCLUSIONS

Remote Australian Aboriginal communities are mainly served by RANs in a health system that is sometimes ill-equipped and at times poorly managed. The theme of a second-class health system being serviced by RANs who felt they were treated as second-class health practitioners appeared throughout the data. Poor distance management practices may contribute to the high turnover of staff in remote Australia. Retention of RANs may increase with better managerial practices, such as effective communication and leadership, staffing replacement and leave, prompt attention to infrastructure issues, and staff development and appraisal. These are the keys to ensuring that RANs feel supported and valued. Remote area nursing is a rewarding career and, with systemic support, RANs may stay longer in remote practice.