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Improving safety in remote clinics: a Q&A with Laura Wright
RN and research student Laura Wright discusses the findings of The Remote Area Safety Project, her mixed methods study involving a literature review, survey, interviews, and policy analysis. What are we doing well, how can we keep nurses safer, and is safety legislation fit for purpose?
What inspired you to investigate remote safety?
The murder of Gayle Woodford back in 2016 and the recommendations that were released from that via the CRANAplus Report, NT Health, and Gayle’s Law. We wanted to know: what’s actually been put in place years later?
What is one recommendation that clinics have followed quite well?
Many clinics now have never alone policies, even though it isn’t widely legislated yet. It’s a relatively new recommendation, so I thought that was pretty good. I think it strengthens the safety net provided by actions like checking up on each other and preventing patients from seeking help at RANs’ houses.
What is a safety recommendation the sector is failing to follow?
One gap is around safe accommodation. One in four participants didn’t even have working fire alarms or working locks on their accommodation.
This point relates to basic requirements required by law through the National Uniform Legislation for Work Health Safety… The WHS legislation requires that in remote or isolated areas where the employer provides the accommodation, they have to maintain it to a standard that doesn’t place the worker at health and safety risks.
But even when [a safety requirement] was specifically legislated it wasn’t necessarily in place.
Do you think some of these facilities were made before safety was a talking point, and now that safety is increasingly discussed, their inadequacies are becoming obvious?
That’s what I’ve heard, especially for the clinic buildings. Quite a few RANs have commented that as the old buildings are being rebuilt or renovated, safety considerations are coming more into it.
But accommodation… A few RANs have said their employers are really on the ball with getting issues fixed, but many more spoke of a lack of response to maintenance requests.
Do the RANs you talked with feel safety education is good enough?
The access to orientation and training needs improvement, but those who did access the training found it helpful. One of my participants did a transition to remote program, and said it was really good within that program. Another participant didn’t even get an orientation and was on call on their first night.
What states and territories are safest?
Some regions are better than others, but it really differed community by community as to how well [safety recommendations] had been implemented. Interestingly, how safe people felt didn’t necessarily relate to how safe their clinic or accommodation was. The vibe of the community also had a big part of it, whether it was seen to be a peaceful community or not.
There were some health services where their policies looked good, but where staff said it’s more of a ‘she’ll be right’ approach. Whereas in other health services, the staff said [management] are completely onto it.
It was also about resourcing; putting their money where their mouth is.
Due to under-resourcing, is there sometimes a conflict in a nurse’s mind between maintaining safety and getting the job done? Does that put nurses in an awkward spot?
Definitely. For example, there were the downsides of trying to run around finding your second responder, if they’re not picking up the phone and you’ve got a sick patient you’ve got to see.
The positive was that when the second responder was provided, when the proper resourcing was there, people were enabled to provide really good care.
How did the nurses you talked with feel about a never alone policy being implemented nationally?
Most feel that the basic recommendations, like never alone [policies], should be across the board, but that there needed to be some variability based on individual clinics and communities. Most seemed amenable to the idea there couldbe a basic set of expectations. For example, everyone should be able to expect to not go on call outs alone, a safe clinic and accommodation, and safe communications equipment. Most of which is already in legislation anyway.
How can the existing legislation become more effective at improving safety?
It would be reasonable to have a set of safety standards that clinics or health services can be held to and assessed against.
Clinics that were doing well at meeting the safety needs of their staff would be able to attract more staff because they’d have a good safety score. Then RANs would be able to make an informed decision when going to work in an unsafe community or clinic.
It would almost improve that pathway so we’re not turning off new staff who are just starting remote and then end up accidentally in an unsafe clinic, going “I cannot deal with this”.
More experienced staff felt better prepared to work in unsafe settings because they’ve built up the strategies to address that and stay safe.
Would a ‘safety score’ exacerbate staffing shortages in some areas?
That’s the problem, it probably would. I guess that could be a strong driver to improve though, because most of these are legislated anyway, so it’s something that does need fixing… It’s such a complex topic. These nuanced discussions are hard to get down into a short article!
You said before that some participants felt never alone policies needed to be flexible. Could you share an example of this?
Not all communities could obtain local drivers as second responders, so in some if they wanted a second person it had to be a nurse.
There was discussion about how to have another person there to improve safety, without creating more safety problems by increasing fatigue.
How important is the inclusion of local drivers as second responders?
You’ve got the safety from the local knowledge they provide.
They can also help nurses to show respect and cultural safety, for example by respecting the boundaries of a men’s business area.
For ages RANs had been saying going out alone on callouts isn’t great, but the response was “we can’t afford to have more nurses” – until Gayle’s murder, when there was a realisation that it doesn’t necessarily have to be another nurse (unless it’s a clinical emergency).
That’s such a good idea – yet this answer never really came up until the crisis. It was a bit like, yes, we’ve finally found a solution. Which gives me hope that for all these other safety issues – which seem so huge – that there is an answer out there. We’ve just got to find it.
How can our readers access your research?
My thesis lays out the findings of all four stages of the project, and they’ll also be published as academic journal articles. I’m sure CRANAplus will be happy to share the link with everyone, and I’ll post them to my LinkedIn account as they become available.