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Collegian
jou rn a l h om e p a g e :w w w . e l s e v i e r . c o m / l o c a t e / c o l l
Reducing occupational stress among registered nurses in very remote Australia: A participatory action research approach
Sue Lenthall
a,∗, John Wakerman
b, Maureen F. Dollard
c, Sandra Dunn
d, Sabina Knight
e, Tessa Opie
c, Greg Rickard
f, Martha MacLeod
gaFlindersNorthernTerritory,FlindersUniversity,POBox433,KatherineNT0851,Australia
bFlindersNorthernTerritory,POBoxU362,CharlesDarwinUniversity,Casuarina,NT0815,Australia
cCentreforAppliedPsychologicalResearch,UniversityofSouthAustralia,CityEastCampus,Adelaide,SA5000,Australia
dCharlesDarwinUniversity,Casuarina,NT0909,Australia
eMtIsaCentreforRuralandRemoteHealth,JamesCookUniversity,MountIsa,QLD4825,Australia
fUniversityofTasmania,DirectorRozelleCampus,SydneyUniversityofTasmania,CornerChurch&GloverSt,LilyfieldNSW2040,LockedBag5052, Alexandria,NSW2015,Australia
gUniversityofNorthernBritishColumbia,3333UniversityWay,PrinceGeorge,BCV2N4Z9,Canada
a r t i c l e i n f o
Articlehistory:
Received18August2016
Receivedinrevisedform13April2017 Accepted27April2017
Keywords:
Remoteareanurses Occupationalhealth Stress
Jobdemand/resources
a b s t r a c t
Background:NursesinveryremoteareasofAustralia(RANs),workincomplexandisolatedsettingsfor whichtheyareofteninadequatelyprepared,andstresslevelsarehigh.Thispaper,basedonthe‘Back fromtheedge’project,evaluatesthedevelopmentandimplementationofaninterventiontoreduceand preventtheimpactofoccupationalstressintheRANworkforceintheNorthernterritory.
Methods:Themethodsinvolvedacombinedparticipatoryactionresearch/organisationaldevelopment model,involvingsevensteps,todevelopandimplementsystemchangeswithinthe(then)NorthernTer- ritoryDepartmentofHealthandFamilies(NTDH&F).Thedevelopment,implementationandevaluation wasinformedviainformationfromparticipantscollectedduringworkshopsandinterviews.Preandpost surveyswereundertakentoevaluatethestudy.
Results:Occupationalstressinterventionsdevelopedbytheworkgroupswerecategorisedintofourmain groups:(1)remotecontext,(2)workloadandscopeofpractice,(3)poormanagement,and(4)violence andsafetyconcerns.Themaininterventionscentredonpromotingawelleducated,stableworkforce.
Therewereveryfewmeasurablechangesasaresultoftheinterventionsasmanywerenotabletobe implementedinthetimeperiodofthestudy,butimplementationiscontinuing.
Conclusion:Whiletheoutcomeevaluationsshowedfeweffects,thestudythroughconsensusapproaches, providesablueprintforreducingstressamongremoteareanursesandevidencewhichshouldinform policyandpracticewithrespecttoservicedeliveryinremoteareas.
©2017AustralianCollegeofNursingLtd.PublishedbyElsevierLtd.Thisisanopenaccessarticle undertheCCBY-NC-NDlicense(http://creativecommons.org/licenses/by-nc-nd/4.0/).
1. Background
Remoteareapracticeischaracterisedbygeographical, social andprofessionalisolation-servicingasmall,dispersedandhighly mobilepopulationwith, high morbidityand mortality,climatic extremes,anextendedpracticerole,amultidisciplinaryapproach andcross-culturalissuesaffectingeverydaylife(Wakerman2004).
NurseswhoworkinremoteareasinAustraliaarecalledremote areanursesor‘RANs’,andaredefinedas
∗Correspondingauthor.
E-mailaddress:Sue.Lenthall@flinders.edu.au(S.Lenthall).
...specialistpractitionersthatprovideandco-ordinateadiverse range of health care services for remote, disadvantaged or isolatedpopulationswithinAustraliaandherTerritoriesand undertakeappropriateeducationalpreparationfortheirprac- tice(CRANA2003).
Nursesworkinginveryremoteareas,asdefinedbytheAccessi- bility/RemotenessIndexofAustralia(ARIA+)(AIHW,2004),arethe mainstayofhealthservicesintheseregions(Lenthall,Wakerman, Dollardetal.,2011).Theyworkincomplexandisolatedsettings thatareoftencrosscultural,andforwhichtheyareusuallyinad- equately prepared(Lenthall,Wakerman, Opie,M.Dollard etal., 2011).
Discussions between different health, professional and uni- versitygroups intheNorthernTerritoryidentified occupational
https://doi.org/10.1016/j.colegn.2017.04.007
1322-7696/©2017AustralianCollegeofNursingLtd.PublishedbyElsevierLtd.ThisisanopenaccessarticleundertheCCBY-NC-NDlicense(http://creativecommons.org/
licenses/by-nc-nd/4.0/).
stressamongRANsasaproblem.In2008,the,NorthernTerritory DepartmentofHealthandFamilies(NTDH&F),CouncilofRemote AreaNursesofAustraliaplus(CRANAplus),CommonwealthHealth Department,OfficeofAboriginalandTorresStraitIslanderHealth, KatherineWestHealthBoard,CentreforRemoteHealth,Flinders UniversityandUniversityofNorthernBritishColombia,Canada, agreedtobepartnersonasuccessfulAustralianResearchCouncil Linkagegrant,‘Backfromtheedge:reducingoccupationalstress amongRANsintheNorthernTerritory’.Theensuingstudyaimed todescribestressors,measurelevelsofoccupationalstressinRANs, anddevelop,implement andevaluateinterventionsthatreduce andpreventtheimpactofoccupationalstressintheremotearea nursingworkplace.Thefirstpartofthestudy,describedstressors andmeasuredlevelsofoccupationalstressinRANsviaasurveyto allregisterednursesinveryremoteAustralia(Opie,Dollardetal., 2010).Giventhehighdemandandunderresourcedenvironment, anextended Job Demands-Resources (JD-R) model (Demerouti, Bakker,Nachreiner,&Schaufeli,2001)wasadoptedtoexamine stressamongRANs.Themodelproposesthatworkerwell-being isaffectedby a numberof variables thatcan becategorisedas eitherjobdemandsorjobresources.Jobdemandsbecomestress- orswhentheemployeeisrequiredtoexpendconsiderableeffort inordertomeetthem,withpossibleoutcomessuchaspsycholog- icaldistressandemotionalexhaustion.Incontrast,jobresources serveamotivationalfunctionandmayleadtopositiveworkout- comes,suchasworkengagementandjobsatisfaction(Opie,Dollard etal.,2010).Additionallyourmodelproposedanumberofsystem capacityfactorsthatcouldinfluencedemandsandresources,such astheclimateforworkerpsychologicalhealth(i.e.,psychosocial safetyclimate,Dollard&Karasek,2010),flexible/adaptableculture (Lenthall,Wakerman,Opie,M.F.Dollardetal.,2011),consultation
&preparation(Lenthall,Wakerman,Dollardetal.,2011),andcom- municationsystems(Lenthall,Wakerman,Dollardetal.,2011).
The results of the first survey confirmed that RANs suffer highlevelsofoccupationalstressandemotionalexhaustion(Opie, Dollardetal.,2010).However,RANsalsoreportedhighlevelsof workengagementandmoderatelevelsofjobsatisfaction.Thejob demandsmoststronglyassociatedwithincreasedlevelsofoccupa- tionalstress,asassessedbyemotionalexhaustionandsymptomsof post-traumaticstressdisorder(PTSD),were:emotionaldemands, responsibilitiesandexpectations,socialissues,workload,staffing issues,poormanagement,isolation,safetyconcerns,violence,the remote context, culture shock, difficultieswith equipment and infrastructure,andlackofsupport(Opieetal.,2009).Thispaper presentstheresultsofthesecondpartofthisstudy,namelydevel- oping,implementingandevaluatinginterventionsthatpotentially reduceandpreventtheimpactofoccupationalstressintheremote areanursingworkforceintheNorthernTerritory.
1.1. Occupationalstressinterventions
Occupationalstressinterventions maybecategorisedbythe type and level of application. Primary interventions are aimed atreducing exposuretopsychologicallyharmfulworkingcondi- tions;secondary,orstressmanagement,interventionsareaimedto enablepeopletouseskillstodealwithpotentiallyharmfulwork- ingconditions;andtertiaryinterventionsareaimedtotreatpeople whohavebeenharmedinsomewaybyworkrelatedstress(Keegel etal.,2007;Lamontagne,Keegel,Louie,Ostry,&Landsbergis,2007).
Interventionsmayalsobecategorisedaccordingtotheirtarget:
individual, group, or the organisation (Cox, Karanika, Griffiths,
&Houdmont,2007;Bergerman,Corabian,&Harstall,2009;Giga, Cooper,&Faragher,2003;Karanikaetal.,2007,).Mostinterventions intheliteraturehaveaimedattheindividuallevel(Coxetal.,2007).
A meta-analysis to determine the effectiveness of stress man- agementinterventionsfoundthatrelaxationinterventionswere
mostfrequentlyused,whileorganisationalinterventions,although describedaspotentiallythemosteffective,continuedtobescarce (Richardson&Rothstein2008).Ratherthantargettheindividual ortheteam,the‘BackfromtheEdge’projectaimedtodevelop primary,secondaryandtertiaryoccupationalstressinterventions, sincecomprehensiveapproachesaremosteffective(Lamontagne etal.,2007).
1.2. Interventionframework
Thisintervention aspectof thestudyis based ontheaction researchmodel ofplannedchange,which involvesboth partic- ipatory action research(M.F.Dollard, le Blanc, &Cotton, 2008) andorganisationaldevelopment.Participatoryactionresearchisa collective,self-reflectiveinquirythatresearchersandparticipants undertaketogethersotheycanunderstandandimproveuponthe practicesin whichtheyparticipate,andthesituationsin which theyfindthemselves(Baum,MacDougall,&Smith,2006).Organ- isationaldevelopmentis‘theprocessofincreasingorganisational effectivenessandfacilitatingpersonalandorganisationalchange throughtheuseofinterventionsdrivenbysocialandbehavioural scienceknowledge’(Anderson2010;p3).Thecombinedparticipa- toryactionresearch/organisationaldevelopment(PAR/OD)model, anadaptationofCummingsmodel,(Cummings&Worley,2008) wasadoptedtodevelopand implementsystemchangeswithin theNTDH&F.Itinvolvedseven‘steps’,withstepsfourtosixbeing repeatedinacyclicalframework(Fig.1).Thismodelwaspartic- ularly pertinentasthis wasan attempttoeffectorganisational change through the harnessing of necessary management and front-linestaffcommitmentandsolutions.InlinewithPARprin- ciples,itattemptedtoaddresspowerrelationshipsbyadoptinga bottomupapproachaimedtoformapartnershipwithparticipants (Dollardetal.,2008).Problemsolvingandenquirywasencouraged anddialoguewasusedtocriticallyexaminerealityandtrytoreach agreementonasharedreality.
1.3. Ethicsapproval
EthicsapprovalwasgrantedbytheCentralAustralianHuman ResearchEthicsCommittee,theTopEndHumanResearchEthics Committeeandtwouniversityresearchethicscommittees.
2. Methods
ThetargetpopulationwereRANsinveryremoteareasinthe NorthernTerritory.Dataonpossibleoccupationalstressinterven- tionsandprocessevaluationswasgatheredthroughworkgroups ofRANsandhealthcentremanagersworkinginremoteAborig- inalcommunitiesinCentralAustraliaandintheTopEndofthe NorthernTerritory.Thesegroups,werefacilitatedbytheleadinves- tigator,generallymetforawholeday,threetimesinthePAR/OD cycledescribedabove.InformationfromthefirstBFTEsurveywere presentedandthendiscussedbytheworkgroups.Theworkgroups thenproposednumerouspossibleinterventions.Participationat alllevelsof theNTDH&Fwasakey strategyintheintervention andtheproposedinterventionswerethenfurtherdeveloped in workshopswithimplementationcommitteescomprisingmiddle managersinCentralAustraliaandintheTopEnd.Someinterven- tionswereimplementedatthemiddlemanagementlevel;others werereferredtothehighlevelreferencegroup.Thisgroupwas createdtoensuretherewascapacityandcommitmenttoimple- mentthedeveloped occupationalstressinterventions.The high levelreferencegroupcomprisedrepresentativesfromtheNTDH&F, theAboriginalMedicalServicesAllianceoftheNorthernTerritory;
theAustralianNursingFederation;theOfficeofAboriginalandTor- resStraitIslanderHealth;andtheCouncilofRemoteAreaNursesof
Fig.1. TheParticipatoryActionResearch/OrganisationalDevelopmentModel.
Australiaplus(CRANAplus).Othermembersoftheresearchteamon thegroupincludedtheDirectoroftheCentreforRemoteHealthand thefirstauthorofthispaper.Theaimsandobjectives,partnerroles andcontributions,andthestudydesignwereagreedatthebegin- ningofthestudy.Threeactionresearchcycleswereconductedover a12-monthperiod.
T-testswereusedtoevaluatetheimpactoftheoccupational stressinterventions,basedonmeansandstandarddeviationsof measuresusedinsurveyone(pre-interventions)andsurveytwo (post-interventions).Pre-andpost-measuresintheintervention groups,theTopEndandCAintheNorthernTerritoryandcontrol group(allotherAustralianstates)werecomparedtodeterminethe following.
•Improvementintotalsystemcapacityincludingthesubscales, responsesofwhichcorrespondedtoa5pointscalerangingfrom (0)stronglydisagreeto(4)stronglyagree,of:-
flexible/adaptableculture(Lenthall,Wakerman,Dollardetal., 2011),whichincludeditemssuch‘myorganisationprogresses effectivelythroughchangeandchallenges’;
consultation & preparation (Lenthall, Wakerman, Dollard etal.,2011),whichincludeditemssuchas‘IfeelIwasade- quatelyinformedabouttheconditionsofhealthcareintheir workplacepriortotakingthisposition;
psychosocialsafetyclimate(Dollard&Bakker,2010;Dollard&
Karasek,2010)whichincludeditemssuchas‘inmyorganisa- tion,seniormanagementshowsupportforstressprevention throughinvolvementandcommitment;
communication(Lenthall, Wakerman, Dollard etal., 2011), whichincludeditemssuchas‘IreceivetheinformationIneed fromcolleaguesandmanagerstoperformmyjobeffectively.
•Improvementinpositiveoutcomesof:
•work engagement, Utrecht Work Engagement Scale9, (Schaufeli&Bakker,2003)withitemssuchas‘Iamenthusiastic aboutmyjob’,andasksrespondentstoindicatethefrequency withwhichtheyexperiencesuchfeelings,ona7-pointscale rangingfrom0(never)to6(everyday);and
•job satisfaction, a single item asking respondents, ‘Taking everything into consideration, how do you feel about your job?’ responses corresponded with a 7-point scale, rang- ingfrom(0)extremelydissatisfied to(6)extremely satisfied (Opie,Dollardetal.,2010).
•Increaseinjobresources,including:-
•supervisionandsocialsupportsubscalesfromtheJobContent Questionnaire(JCQ)(Karaseketal.,1998),whichincludeditems suchas‘mysupervisorisconcernedaboutthewelfareofthose underhim/her’,and‘peopleIworkwitharehelpfulingetting thejobdone’, responsescorrespondedwitha5-pointscale, rangingfrom0(stronglydisagree)to4(stronglyagree);
•opportunityforprofessionaldevelopment,basedonthework ofAikenandPatrician(2000)andincludeditemssuchas‘there areactive in-service/continuingeducationprogramsforme’
withresponsesrangingfrom0(stronglydisagree)to4(strongly agree).
•jobcontrolandpossibilitiesfordevelopment,fromtheCopen- hagen Psychosocial Questionnaire (COPSOQ), (Kristensen, 2000),includedsuchitemsasItemsas,suchas‘Icandecide when totake a break’ for jobcontrol and ‘does your work requireyoutotakeinitiative?’withresponses,corresponding witha5-pointscale,rangingfrom0(toalargeextent)to4(toa verysmallextent).
•Decreaseinnegativeoutcomesof:-
•psychologicaldistress,measuredbytheGeneralHealthQues- tionnaire12 (GHQ12)(Goldberg and Williams, 1991), which includesitemsssuchas,‘haveyourecentlylostmuchsleep overworry?’responsescorrespondedtoa4-pointscaleranging from1(notatall)to4(muchmorethanusual);
•emotional exhaustion subscale from the Maslach Burnout Inventory(Jacksonetal.,1996;Maslach,Jackson,&Leiter,1996), whichincludesitemssuchas‘Ifeelemotionallydrainedfrom mywork’,withresponsescorrespondingwitha7-pointscale rangingfrom0(never)to6(everyday);and
•symptomsofposttraumaticstress,PostTraumaticStressDis- orderChecklistPCL(Weathersetal.,1993),whichprovidesa listof17fundamentalsymptomsofPTSDwhichareclustered intothreemainsymptomcategories,includingre-experiencing symptoms(e.g.nightmaresorflashbacks),hyperarousalsymp- toms(e.g.easilystartled),andavoidanceandpsychicnumbing symptoms(e.g.tryingtoavoidactivities,placesorpeople).It asks respondentstorate“ifandhow”theyhavebeenboth- eredbyanyofthelisted“reactions”(symptoms)overthepast month, in relationtoatraumatic experienceorevent,with responsescorrespondingwitha5-pointscalerangingfrom(1) notatallto(5)extremely.
•Decreaseindecreaseinjobdemands−measuredbythefollowing
•Witnessedviolenceandpersonalviolence,wherebothasked respondentshowoftentheyhadexperienceddifferentman- ifestationsofworkplaceviolenceinthepreceding12months, withresponsescorrespondedwitha4-pointscalerangingfrom (0)neverto(4)fourtimesormore,(Opie,Lenthalletal.,2010).
•Emotionaldemands,usingtheemotionaldemandssubscaleof theCOPSOQ(Kristensen,2000)whichincludeditemssuchas
‘doesyourworkputyouinemotionallydemandingsituations’
withresponsescorrespondingtoafivepointscalerangingfrom (0)veryrarely/neverto(4)veryoften/always.
•ThroughtheRANSpecificStressScale,whichwasdevelopedby afocusgroupattheCouncilofRemoteAreaNursesofAustralia (CRANA)conferencein2007andfurtherrefinedusingaDel- phitechniqueinvolvingrepeatedconsultationwithapanelof experts.Thereweretwelvegroupsofidentified stressorsall correspondingtoa7-pointscale,rangingfrom(0)neverto(6) everyday,including:-
1)poormanagement,withmanagementbeingdefinedastheper- sonwhohasmanagementauthority overtheirposition,for example,themanagerintheRegionalCentre/Townforremote areanurses,itemsincluded‘howoftendoesyourmanagerfail toaddressissuesraisedconcerningcolleagues’;
2)staffingdifficulties,itemsincluded‘howoftendoyouexperi- enceinadequatestaffinglevels;
3)on-call,itemsincluded‘howoftenareyouon-call24haday;
4)workload,items included ‘howoften do you perceive your workloadasunmanageable;
5)responsibilitiesandexpectations,itemsincluded,‘howoften dotheresponsibilitiesofthehealthserviceexceedthecapacity ofstaff’;
6)safetyconcerns,itemsincluded‘howoftendoyoufeelcon- cernedaboutyourpersonalsafety;
7)socialIssues,itemsincludedhowoftendoyouexperiencedif- ficultyinitiatingormaintainingsocialinteraction
8)isolation,itemsincluded,‘howoftendoyoufeelisolatedfamily andfriends’;
9)inter-culturalfactors,itemsincluded‘howoftendoyouexperi- enceconflictbetweenwesternnursingpracticesandprevailing culturalpractices’;
10)cultureshock,itemsincluded‘howoftendoyouexperience uneasinessaboutlivingorworkinginadifferentculture’;
11)lackofsupport,itemsincluded‘howoftendoyouexperience adequatementorsupport’;
12)infrastructureandequipmentdifficulties,itemsincluded‘how oftendoyouexperiencedifficultieswithequipment’.
DatawereanalysedusingtheStatisticalPackagefortheSocial Sciences(SPSS)forWindows,version16.
Processevaluationswereconductedatworkshopsandcommit- teemeetingstogaugetheeffectivenessoftheinterventionprocess.
Informationpertainingtotheprocesswasalsocollectedthrough minutesof meetings, observationsof workshops andmeetings, adiaryofmeetings,aswellasinterviewswithkeyrespondents, includingtwo members of thehigh level referencegroup, two membersoftheTopEndimplementationgroupandthreemembers oftheCAimplementationgroup.
One section of survey two, adapted from evaluation of the Victorian Workforce Authority, (Victorian Workforce Authority, 2006)askedparticipantsabouttheirlevelsofengagementinthe project,levelsoftrust,andlinemanagerattitudesandactions.
3. Results
3.1. Occupationalstressinterventions
OccupationalStressInterventionsdevelopedbytheworkgroups were organised intofour main categories following analysis of commonthemes:(1)remotecontext,(2)workloadandscopeof practice,(3)poormanagement,and(4)violenceandsafetycon- cerns.ThespecificinterventionsarelistedinTable1.
3.1.1. Remotecontext
The remote context impacts on all of the job demands, and a number, including emotional demands, social issues, staffingissues,interculturalfactors,isolationanddifficultieswith equipmentand infrastructureare intrinsicallylinked.Nearlyall participantsin theworkgroups agreed that working in remote communitieswasmoreemotionallydemandingthanmostother jobs they had previously undertaken. Some elements of emo- tionaldemands,suchasthepoorhealthofAboriginalpeoples,the frequencyofemergencies,andtheregularityofapre-existingrela- tionshiporassociationbetweentheRANandclientcouldnotbe changedbyoccupationalstressinterventionsinthescopeofthis project.However,manyoftheinterventionsdevelopedtoaddress otherareas,suchasimprovededucationandsupport,couldassist RANstocopewiththesedemands.
RANs found social issues such as establishing professional boundaries,findingtimetounwind,initiatingormaintainingsocial interaction, and maintaining personal relationships, difficult to manage.Themaininterventionaimedtoimprovesocialsupport andinteractionwastointroduceinternetconnectionsinallRANs’
accommodation.
SomeRANsreportedthatstaffingissueshadamajorimpacton stresslevels.Theyalsoreportedalackofreliefstaff.ManyRANsand healthcentremanagersreportedbeingtiredofcontinuallyorien- tatingnewstaff.TherewasalsoconcernexpressedbysomeRANs aboutthecapabilitiesofshort-termstaffandthelackofcontinuity ofcare.Toaddressthelackofreliefstaff,RANsproposedtoidentify thenumberofreliefpositionsrequired,andincreasethenumber ofrelieversandestablishapermanentreliefpool.
MostRANsreportedfacinga range of challenges relatingto cross-cultural environments.These included differences in lan- guage,socialnormsand genderroles,disparityinreligiousand spiritual practices, and contestedvalues and beliefs relating to healthandillness.Therewasconsiderablediscussionaboutfeeling caughtbetweenwesternnursingpracticesandprevailingcultural
Table1
Summaryofoccupationalstressinterventions.
ProposedIntervention ImplementedbyJan2015yes/no
Remotecontext Emotionaldemands
ImproveeducationandorientationofRANs Yes,exceptforagencystaff
Reduceorientationburnout Highstaffturnoverhaspreventedthisfrom
happening Socialissues
Introduceinternetconnectioninallaccommodation No
Staffingissues
Extrapositionscreatedtoreducesinglenurseposts Yes
Increasepermanentreliefstaff No
IncreasenumberofRANs Therehasbeensomeincrease
IncreaseofAboriginalstaffemployed AnumberofadditionalAboriginalcommunity
workershavebeenemployed Increaseemploymentandtrainingofancillarystaffincludingadmin,cleanersanddrivers Yes
Increasereliefstaffbyincreasingowncasualpool No
Identifyreliefpositionnumbers No
AdvertisingRANcampaigninAliceSprings No
Inter-culturalfactors
IncreaseorientationandeducationofRANsonculturalissues Yes
Isolation
Internetconnectioninallaccommodation No
Equipmentandinfrastructure
Improvemanagementbyemployinganequipmentmanager Yes
Improvefeedbackaboutminornewworksbyintroducingfeedbacksystem Yes
Improveabilityofclinicstopurchaseminoritemseasilybyintroducingcreditcards Yes Ensurepromptevacuationsbyretenderofair-medicalcontract(topend) Yes
Introducetrackingsystemforrepairs No
Ensureloanequipmentsamestandardasclinicequipment No
Investigatetravellingteamsofplumberandelectrician No
Areaservicemanagerstoreviewsystemofrepairsforeacharea No
Increasenumberofvehiclestoensureeverycommunityhastwo Ongoingduetofundingimplications
Introducestandardfitoutofambulances(TopEnd) No
Increaseaccommodation No
Lobbyforadditionalaccommodation On-going
Increasecleanlinessofclinicsandaccommodationwithamajorcleanonceayearbyvisitingteams No RANs,visitorstopayabondorchargedacleaningfeeifaccommodationleftinunacceptablecondition No
Healthcentremanagerstomonitorconditionofaccommodation No
WorkloadandResponsibilitiesandexpectations Responsibilitiesandexpectations
IntroducecareerpathwayforRANs,allowingsometobelearners Yes,Level3positionsestablished Strengthenpathwaysprogram(educationprogramforRANS)orcreateanewprogram No
Establishasteeringgrouptodrivethestrengtheningprogram No
Introducemoreon-siteeducation No
Employadditionalremoteeducators Yes
IncreasenumberofRANshavingaperiodofonetoseveralweeksinRoyalDarwinHospitalforupskilling (TopEnd)
No EnsureappropriateorientationofallRANsandreduceorientationburnoutamongstaffby:
-introducingbuddyingsystemforallnewRANs(whenpossible) No
-investigatingonlinemodulesthroughAustralianNursingFederation(ANF),RemoteAreaHealthCorp (RAHC),CentreforRemoteHealth(CRH),CRANAplus
Yes
-investigatingthepossibilityofavirtualclinic Investigatedbutnofundingavailable
-developorientationinformationforRemoteHealthwebsite Yes
-redeveloporientationpackage yes
Workload
Increasecoordinationofvisitingteamstoreduceworkload Yes
IncreasetrainingonNTDH&Felectronicsystemstoreduceworkloadonfillinginforms Yes Increaseemploymentandtrainingofancillarystaffincludingadministration,cleanersanddrivers No
IncreasenumberofRANs Increasing
Support
Improveorientationandeducation Yes,exceptforagencystaff
Increasenumberofremoteeducators Yes
On-call
Increasestaffnumberstoreducethefrequencyofon-callforallstaffmembers Gradual Management
Establisheducationrequirementsformanagers,linkedtocareerpathway No
Healthcentremanagerstoundertakegraduatestudy No
Createscholarshipsx5offeredtohealthcentremanagers No
Increaseinformationfromexitinterviewsreceivedbymanagementteam No
IncreasethenumberofRANscompletingexitinterviews No
Introducefeedbacksystemformanagementbydistributingemployeeopinionsurvey No Violenceandsafetyconcerns
Workplaceviolence
Improveon-callsystems Yes
Improveunderstandingandreportingofvicarioustrauma,PTSDforhealthcentremanagersandRANsby providingeducation
No
Table1(Continued) Safetyconcerns
AreaservicemanagerstoundertakeareviewofsecurityandreporttoOH&S No Reintroducemanagingaggressionandriskmanagementaspartoforientation Yes Improvesafetywhileon-callby:
-installationofphonesystemsinallclinics Ongoing
-ImproveOH&SbyintroducingOH&Scommittee,withaseniormanageroncommittee No
-IntroduceRiskManinreportingofcriticalincidents Yes
-Increaseuseofescortsforon-callatnight No
HLRG,highlevelreferencegroup;RANs,remoteareanurses;ANF,AustralianNursingFederation;RAHC,RemoteAreaHealthCorp;CRH,CentreforRemoteHealth;CRANAplus, CouncilofRemoteAreaNursesofAustraliaplus;DoH&F,DepartmentofHealthandFamilies;OH&S,occupationalhealthandsafety;PTSD,post-traumaticstressdisorder;
TE,TopEnd.
practices.Theinterventionssuggestedwereincreasedorientation andeducationofRANsonculturalissues.
Thedifficultieswithinfrastructureandequipmentandinpar- ticular,withmaintenance,causedagreatdealoffrustrationamong RANsandhealthcentremanagers.Thevastdistancescontributed greatlytothedifficultiesandexpenseingettingequipmentand infrastructurerepaired.Toimprovethemanagementofequipment, RANsproposedtoemployanequipmentmanager,tointroducea trackingsystemforrepairs,andtomakeloanequipmentthesame standardandmodelasclinicequipment.RANsalsorecommended thatallhealthcentreshaveaminimumoftwovehicles.Thelack ofaccommodationinmanycommunitieswasidentifiedaslimiting thenumberofon-sitestaff,visitingteamsandtheabilityofhealth centrestotakestudents.Itwasalsoagreedthataccommodation neededtobeincreased.
3.1.2. Workloadandscopeofpractice
Thenatureofnursingpracticeinremoteareasisuniqueand hasimplicationsforthelevelofresponsibilitiesandexpectations ofthecommunityandtheemployers,workload,difficultieswith support,andtheon-callthatRANsarerequiredtodo.Therewas acommonlyheldviewamongRANsthattheremotecommuni- tiesandhealthserviceshaveunrealisticexpectationsthatcannot bemet.Thisisoftenexacerbatedbytheadvanced practicerole thatRANsarerequiredtoperformwithoutadequateprofessional preparation.
Theseresponsibilitiesandexpectationswerelinkedtothelack oforientationandinadequateeducationfor theadvanced prac- ticerolesrequiredinremotecommunities.Suggestedinterventions includedtheintroductionofmoreon-siteeducatorsandencour- aging RANs to have a training period in the local hospital for up-skilling.
Lackoforientationwasakeyissuerelatedtoresponsibilitiesand expectations.Only65%ofRANsintheNTreceivedanorientationto theirposition,andforthosethatdid,lessthanhalfthoughtitwas adequate(Lenthall,Wakerman,Dollardetal.,2011).The‘frontline’
natureofremoteareahealthworkandthelackofresidentmed- icalandalliedhealthpractitionersdictatethatnursesaresubject togreaterworkloads(Lenthall,Wakerman, Dollardetal.,2011).
Nearlyallworkshopparticipantsreportedfeeling overwhelmed bythe volume ofwork theywere expectedto do. Participants reportedthattheon-callrequirementsandthefrequentturnover ofstaffexacerbatedthissituation.Themaininterventionincluded increasedstaff,inparticularincreasedAboriginalstaff,inallareas oftheremotehealthservice.
AnothermajorworkloadissueidentifiedbyRANsand health centremanagerworkgroupswastheworkloadcreatedby“flyin/fly out”visitingteams.Remotecommunitiesmaybeservedbyspe- cialistoutreachteamssuchascardiologyandobstetrics,aswell asvisitingteamssuchasmidwifery,childhealth,rheumaticheart diseaseandexternalorganisationssuchastheFredHollowsFoun- dation.Therewas little coordination ofteam visits, withsome arrivingwithoutnoticeandtwoormorearrivingatthesametime.
Workgroupssuggestedthatvisitingteams:(1)bepartofthe expansionoftheclinicteam;(2)workwiththeclinicteamonmat- tersthattheclinicteamidentify;(3)scheduleasetnumberofvisits peryear;(4)donotjointhedoctor’scharterplanevisitasthedoc- tor’sclinicisalreadybusy;(5)askhealthcentremanagerswhenisa convenienttimetovisit;(6)donotbringadditionalpeoplewithout checkingwiththehealthcentremanagers;(7)haveprotocolsfor visitingteamsestablishedineachdistrict;and(8)havecalendars thathavebeennegotiatedsenttothehealthcentremanagersfor agreement.
3.1.3. Poormanagement
RANsandhealthcentremanagersidentifiedpoormanagement asakeyissue.NearlyallRANsreporteddifficultieswithmiddle orseniormanagement.Manyfeltunsupportedbymanagersand theyfeltthatsomemanagershadapoorunderstandingoftheir roles as RANs.They perceivedthat this wasworse the further managerswerefromthe‘grassroots’.Membersoftheimplemen- tationcommitteeandthehighlevelreferencegroupassessedthat attimesthecomplaintsaboutmanagementwerenotlegitimate.
Theyperceivedthatmanagementwasaneasytargetforunhappy RANs.However, all participantsagreed that educationrequire- mentsshouldbeestablishedformanagers,andtheserequirements shouldbelinkedtocareerpathways.
3.1.4. Violenceandsafetyconcerns
Violenceandsafetyconcernswerestronglylinked.Manyofthe safetyconcernswererelatedtoviolencewithinthecommunityor towardsRANs.Intheworkgroupsthereweremarkeddifferencesin participants’concernsaboutworkplaceviolence.Whilesome,par- ticularlythosewhohadexperiencedpersonalviolence,werevery concerned,othersdidnotconsiderworkplaceviolenceanissue atall.Interventionsincludedreducingsinglenurseclinics,intro- ducingon-callphonesystemsandincreasingtheuseofdriverson call-outsafterhours.Itwasalsoagreedtoimproveunderstand- ingandreportingofviolentincidentsbyprovidinghealthcentre managersandRANswitheducationonvicarioustraumaandpost- traumaticstressdisorder.
3.2. Priorities
The workgroups and implementation committee in Central AustraliaandtheTopEndwereaskedtoprioritisetheoccupational stressinterventions.InCentralAustralia,thefivehighestpriorities inorderwere:(1)permanentreliefstaff;(2)improvededucationof RANs,includingadequateorientationforallstaff;(3)aminimum oftwovehiclesateachcommunity;(4)employmentofanequip- mentmanager;and(5)increasedstaff,especiallyAboriginalstaffat cliniclevel.TheTopEndworkgroupsandimplementationcommit- teeagreedonsixpriorities:(1)adequatestaff;(2)asecondvehicle in each community withstandard basicfit outof ambulances;
(3)increasedRANaccommodation;(4)increasedpermanentrelief
pool;(5)improvededucationforRANs;and(6)internetaccessin allaccommodation.
3.3. Implementationofoccupationalstressinterventions
Someinterventionswereimplemented, howevermanywere not.ThesearesummarisedinTable1.
3.4. Evaluation
3.4.1. Processevaluation
Feedback provided in thepost-workshop evaluationsurveys wasmainlypositive.ParticipantsfoundtheRANandhealthcen- tremanagerworkgroupsandimplementationcommitteemeetings generallyinterestingandengaging,thefacilitatorseffective,and participantsthoughtthattheirinputwasvalued.Incontrast,the resultsfrom the process evaluation obtainedfrom survey two, completedsomemonthsaftertheendofthePAR/organisational developmentprocess,werefarlesspositive.Themajority26of37 respondents(71%)feltthatlittleornotrusthadbeenbuiltduring theprocess,and29of37(79%)respondentsthattheactionplans oftheinterventionshadnotbeensubstantially.
3.4.2. Outcomeevaluation
Therewasasignificantimprovementindifficultieswithinfras- tructureandequipmentintheTopEnd.Therewasanimprovement inlackofsupportinCA,howevertherewasalsoanimprovement insupportinthecontrolgroup.Therewerenoothersignificant improvementsamongtheothervariables(SeeTable2).
Therewerealsonoimprovementsovertheprevious12months intheareasofworkload,education,staffreliefandmanagement forCAorfortheTopEnd(seeTable3).
4. Discussion
Numerouspractical and thoughtful interventionsrelating to staffing,training,safetyandimprovinginfrastructureandequip- mentwereidentified.Theemphasisassuggestedbytheliterature focusedondeveloping primary, secondary andtertiary occupa- tionalstressinterventions.However,theimplementationofmany oftheseinterventionsprovedtobeextremelydifficult.Therewere fivemain reasonsidentified by theresearchteam for thenon- implementation.Firstly,therewereanumberofcontextualissues thatwereimpossibletoinfluenceorovercome.Thehighturnoverof RANsandthedifficultyinrecruitmentofRANsresultsinavicious cycle.Itisdifficulttoreduceoccupationalstressandimplement manyoftheinterventionswithsuchanunstableworkforce.Second, therewasalackoffundingtoresourcetheimplementationofinter- ventions.Whilstservicepartnerscontributedincashandinkindto thestudy,therewasnoadditionalfundingbytheserviceprovider toimplementtherecommendedinterventions.Third,lowerstan- dardsofequipmentandinfrastructureinremotecommunitiesare oftenacceptedbyhealthservices,staffandcommunitymembers.
Maintenance of buildings and equipment wasoften below the acceptablenationalstandardsinremotecommunities.
Fourth,therewereinteragencycomplexities.Someofthebuild- ingsandaccommodationareownedbydepartmentsotherthanthe NTDH&Fandotherdepartmentshaveauthorityovervariouspieces ofequipment.Implementingsomeoftheinterventionsrequired agreementbymultipledepartmentsandprovedextremelycom- plex.Lastly,theimplementationperiodof12monthswasprobably tooshorttoimplementmanyoftheinterventions.Itisimportant tonotethatimplementationhascontinuedaftertheendofthe studyanditishopedmoreoccupationalstressinterventionswill beimplementedinthefuture.
ViolenceandsafetyofRANsremainsamajorissue.Thiswas tragicallyhighlightedbythemurderofaRANinSouthAustralia atEaster2016.ThedeathhaspromptedmanyRANsandorganisa- tionstoexaminetheirsafetypractices.Inparticulartherehasbeena strongmovementtolimitRANsattendingcalloutsatnightontheir own,consistent,sadly,withthe‘BackfromtheEdge’studyfind- ingsandrecommendations.TheNTDepartmentofHealthreporton remoteareanursesafety(NorthernTerritoryDepartmentofHealth, 2016),frequentlycitedpapersfromtheBFTEstudyandrecommen- dationsthatwerenotpreviouslyimplementedincluding;
•thatafterhourscall-outsinremotecommunitiesareundertaken byateamoftwopeople(Recommendation1a);
•minimumorientationrequirementsaremandatedforallremote PrimaryHealthCarestaff(Recommendation5a);
•considerationisgiventoprovidingstandardisedinternetaccess innurseshousestofacilitateaccesstoon-lineresourcesincluding procedures,protocolsandlearningmodules(Recommendation 5c);
•re-introductionofarelievingstaffpool(Recommendation6);
•strengthen‘BackonTrack’,Indigenousemploymentinitiatives acrossallemploymentcategories forAboriginal staff(Recom- mendation8)(NorthernTerritoryDepartmentofHealth,2016).
Itisexpectedthattheimplementationofmanyoftheoccupa- tionalstressinterventions,willbeongoingforsomeyears.
5. Limitations
Priortoandduringtheresearchperiod,therewasconsiderable turmoilwithinremoteAboriginalcommunitiesandhealthservices intheNT.Therewasagreatdealofpoliticalactionincludingthe AustralianGovernmentInterventionintotheNT,acontroversial package ofchangestowelfareprovision,lawenforcement,land tenureandothermeasures,introducedbytheAustralianfederal governmentunderJohnHoward,beginningin2007andcontinuing throughouttheproject.In2009,whentheworkgroupsofRANsand healthcentremanagerswerebeingconducted,therewasanout- breakofH1N1influenza(humanswineflu).Considerableresources withintheNTDH&Fwereredirectedtomanagingthisoutbreak.
ThisgreatlyincreasedtheworkloadofRANs,healthcentreman- agers,and managerswithinthehealthdepartmentandmadeit moredifficultforsomeunitstoattendtheworkshops.
6. Conclusions
The‘Backfromtheedge:reducingoccupationalstressamong RANsintheNorthernTerritory’studyusedanadaptedPAR/OD modeltodevelopandimplementoccupationalstressinterventions.
Theprocessevaluationsoftheworkshopswereverypositivebut theoutcomeevaluationsshowedlowimplementationofinterven- tionsandlow impactonsourcesand outcomesofoccupational stress.Nevertheless,thenewknowledgecreatedbythestudyis useful.Theissuesrelatingtocreatingastable,well-educatedand well-managedworkforcewiththephysicalresourcesrequiredto fulfilachallengingjobremainoutstandingandwillnotgoaway withoutfurtherintervention.
Thenewknowledgegeneratedinthisstudyshouldinformpol- icyandpracticewithrespecttoservicedeliveryinremoteareas.
Thereareimplicationsinregardtoservicemodels.Theseneedtobe adequatelyresourced,staffbetterpreparedandservices,especially visitingservices,betterco-ordinated.Tomaximiseeffectiveness, thereneedstobegreaterinterdepartmentalco-ordinationorratio- nalisationinordertoensurethetimelymaintenanceofessential equipmentandinfrastructure.
Table2
NTsamplesandcontrolgroupoutcomemeasures.
TopEnd CA Control(otherRNsinvremote
communitiesoutsidetheNT
Survey1 Survey2 Survey1 Survey2 Survey1 Survey2
Systemcapacity Totalsystemcapacity
Number 32 43 30 25 59 83
Mean 26.13 24.63 22.23 22.52 25.61 25.12
SD 7.49 9.63 8.27 6.97 9.29 9.12
Sig. p=0.81n/s p=0.41n/s p=0.66n/s
Flexibleandadaptableculture,Subscaleofsystemcapacity
Number 35 60 27 26 61 89
Mean 5.09 4.6 4.19 4.08 4.72 4.31
SD 1.77 1.65 1.78 1.65 2.00 2.12
Sig. p=0.18n/s p=0.35n/s p=0.68n/s
Consultationandpreparation,Subscaleofsystemcapacity
Number 34 44 26 26 61 84
Mean 8.82 8.91 7.73 8.50 9.11 8.90
SD 2.68 3.48 3.04 2.45 3.05 3.58
Sig. p=0.94n/s p=0.15n/s p=0.90n/s
Communication,Subscaleofsystemcapacity
Number 35 57 27 27 63 89
Mean 4.14 4.42 3.70 4.07 3.98 4.04
SD 1.96 1.86 1.92 1.86 1.96 1.92
Sig. p=0.36n/s p=0.44n/s p=0.43n/s
Psychosocialsafetyclimate,Subscaleofsystemcapacity
Number 33 45 31 27 62 88
Mean 12.09 11.27 10.71 9.78 12.02 12.15
SD 3.52 4.21 3.68 2.89 3.70 3.87
Sig. p=0.83n/s p=0.11n/s p=0.64n/s
Positiveoutcomes Workengagement
Number 33 55 27 26 60 88
Mean 4.61 4.54 4.42 4.56 4.35 4.41
SD 1.07 1.03 1.24 0.98 1.22 1.18
Sig. p=0.76n/s p=0.65n/s p=0.77n/s
Jobsatisfaction
Number 35 53 27 26 61 85
Mean 4.29 4.02 4.26 4.31 4.16 4.19
SD 1.07 1.41 1.40 1.26 0.97 1.16
Sig. p=0.34n/s p=0.89n/s p=0.87n/s
Jobresources Supervision
Number 34 57 26 26 63 87
Mean 11.62 10.79 9.38 9.38 9.03 9.47
SD 3.59 4.13 3.32 5.05 3.94 4.66
Sig. p=0.33n/s Nodifference p=0.92n/s
Opportunitiesforprofessionaldevelopment
Number 34 57 27 27 63 89
Mean 9.29 9.25 9.56 8.70 8.41 8.13
SD 3.09 3.62 3.79 3.21 4.30 4.03
Sig. p=0.83n/s p=0.64n/s p=0.92n/s
Jobcontrol
Number 33 52 23 25 61 88
Mean 21.55 24.19 24.83 23.76 21.05 22.82
SD 8.07 8.31 9.25 9.12 8.20 8.47
Sig. p=0.15n/s p=0.47n/s p=n/s
Negativeoutcomes Psychologicaldistress,GHQ
Number 34 57 27 26 62 88
Mean 13.58 13.12 11.56 12.58 12.08 11.56
SD 7.08 6.94 5.27 6.23 5.31 5.10
Sig. p=0.81n/s p=0.52n/s p=0.54n/s
Emotionalexhaustion
Number 33 62 29 27 63 88
Mean 20.82 20.01 25.33 20.59 21.42 20.11
SD 14.02 12.76 14.66 11.97 12.62 12.13
Sig. p=0.78n/s p=0.19n/s p=0.60n/s
PTSDSymptoms,Posttraumaticstressdisorderchecklist(PCL)
Number 34 56 26 27 60 87
Mean 10.41 11.34 11.19 9.89 10.72 9.77
SD 11.74 12.17 10.54 11.00 10.71 12.01
Sig. p=0.72n/s p=0.66n/s p=0.62n/s
RANStressScale WitnessedViolence
Number 33 55 27 27 60 86
Mean 11.64 14.75 9.63 10.93 9.77 9.88
SD 6.10 8.91 6.81 5.87 6.44 6.33
Sig. p=0.98n/s p=0.23n/s p=0.44n/s
PersonalViolence
Number 34 53 27 26 60 88
Mean 5.85 7.15 5.44 5.81 5.95 6.38
SD 4.55 5.31 4.49 4.35 4.98 5.16
Table2(Continued)
TopEnd CA Control(otherRNsinvremote
communitiesoutsidetheNT
Survey1 Survey2 Survey1 Survey2 Survey1 Survey2
Sig. p=0.24n/s p=0.44n/s p=0.61n/s
Emotionaldemands
Number 34 57 27 27 63 89
Mean 8.32 7.88 7.78 7.63 7.19 7.01
SD 2.04 3.02 3.25 2.63 2.79 2.66
Sig. p=0.45n/s p=0.14n/s p=0.69n/s
Poormanagement
Number 34 43 24 24 57 86
Mean 13.32 16.05 14.67 16.50 14.77 15.74
SD 9.86 11.63 10.60 10.09 10.75 12.46
Sig. p=0.28n/s p=0.54n/s p=0.34n/s
Staffingdifficulties
Number 35 44 26 26 60 86
Mean 13.03 13.27 11.77 12.38 8.55 11.92
SD 6.61 7.44 7.24 6.71 6.41 9.23
Sig. p=0.76n/s p=0.35n/s p=0.016*
On-call
Number 35 45 27 26 60 85
Mean 15.63 17.69 18.19 17.73 16.93 18.47
SD 4.26 6.44 3.10 7.81 8.21 7.12
Sig. p=0.11n/s p=1n/s p=0.75n/s
Workload
Number 35 45 26 27 61 89
Mean 21.54 20.76 22.00 19.37 18.54 17.63
SD 5.39 6.82 5.96 7.76 7.21 6.18
Sig. p=0.58n/s p=0.16n/s p=0.41n/s
ResponsibilitiesandExpectations
Number 35 45 27 26 60 85
Mean 25.11 25.69 21.78 22.08 23.92 21.93
SD 9.50 12.59 11.56 10.33 11.55 11.81
Sig. p=0.97n/s p=0.29n/s p=0.46n/s
Safetyconcerns
Number 35 44 27 26 63 88
Mean 9.23 11.59 9.22 9.12 10.81 10.68
SD 7.20 8.65 7.38 6.41 8.69 7.52
Sig. p=0.199n/s p=0.24n/s p=0.11n/s
Socialissues
Number 35 44 27 27 63 87
Mean 9.37 8.48 9.37 10.11 10.52 9.02
SD 6.20 6.56 5.20 5.67 6.43 6.16
Sig. p=0.54n/s p=0.67n/s p=0.15n/s
Isolation
Number 35 45 27 27 63 88
Mean 9.14 10.69 11.07 11.15 10.84 12.08
SD 5.87 6.24 6.20 6.35 6.18 6.59
Sig. p=0.26n/s p=0.55n/s p=0.25n/s
Interculturalfactors
Number 35 45 26 27 62 89
Mean 10.86 10.33 12.27 10.19 7.24 8.36
SD 4.09 5.70 6.00 5.02 6.34 6.38
Sig. p=0.98n/s p=0.18n/s p=0.29n/s
Cultureshock
Number 35 45 26 27 62 89
Mean 8.03 6.56 10.35 7.41 6.58 6.27
SD 5.47 6.23 7.41 6.01 6.99 6.65
Sig. p=0.27n/s p=0.12n/s p=0.33n/s
LackofSupport
Number 33 44 26 27 63 88
Mean 15.94 13.64 17.50 12.22 17.54 13.51
SD 6.87 6.97 6.59 5.33 6.49 7.52
Sig. p=0.15n/s p=0.0023** p=0.0008**
Infrastructureandequipmentdifficulties
Number 35 45 27 26 59 88
Mean 20.66 25.58 25.07 22.15 17.90 19.20
SD 8.33 11.28 8.53 8.53 9.14 11.06
Sig. p=0.034* p=0.22n/s p=0.46n/s
n/s,notsignificant,*significant,**highlysignificant.
CA,CentralAustralia.
Highernumbers=higherlevels.