It is safe to say of the ear­ly days that CRANA’s aspi­ra­tions exceed­ed its bud­get. Before 1991, CRANA was run by vol­un­teers work­ing in their lounge rooms and using fax and phone to communicate.¹ It had received spo­radic fund­ing for con­fer­ences and projects but rather than restrict itself to its fund­ing streams, it built itself into a com­mit­ted com­mu­ni­ty organ­i­sa­tion around them.

In 1987, CRANA pub­lished its first newslet­ter, the 8‑page Out­back Fly­er². In 1988, the organ­i­sa­tion became incor­po­rat­ed under the Asso­ci­a­tions Act, Vic­to­ria. The mod­est Mem­ber­ship rev­enues of the day built up a small work­ing fund that allowed CRANA to pur­sue these goals. In 1991, Mem­ber­ship cost $50, or $25 for stu­dents, and the organ­i­sa­tion had 287 Members.

The organisation’s hori­zons expand­ed in 1991, when CRANA received $50,000 in fund­ing towards its Nation­al Sec­re­tari­at from the Fed­er­al Depart­ment of Health, Hous­ing and Com­mu­ni­ty Ser­vice. Sud­den­ly, it could appoint an Exec­u­tive Offi­cer and open its first office. The first EO was Bernie Ibell who was based in Tas­ma­nia but the organ­i­sa­tion soon shift­ed to Cairns, where it set up shop in a mod­est two-room office.

CRANA’s first major fund­ed project

CRANA was right on cue. Still hang­ing the wall­pa­per in the new office so to speak, it found itself respond­ing to an evolv­ing sit­u­a­tion on Cape York.

Sal­ly John­son was CRANA pres­i­dent in the ear­ly 1990s. She explains that at one stage there was an aver­age of one assault of nurs­es per month on the Cape and that in some remote com­mu­ni­ties the turnover rate exceed­ed 200 per cent.

“I was par­tic­u­lar­ly con­cerned that it was dif­fi­cult for nurs­es to stay in remote areas, because I knew that our best work was done after the first few years in a com­mu­ni­ty, when trust had been earned on both sides,” Sal­ly says.

“At that time Indige­nous groups and com­mu­ni­ties were deal­ing heav­i­ly with results of dis­pos­ses­sion of their land, forced relo­ca­tion, sep­a­ra­tion from fam­i­ly, exter­nal con­trol, rapid social change and many oth­er trau­mat­ic events asso­ci­at­ed with colonisation.”

Sal­ly spoke exten­sive­ly with the media at this time and in the back­ground, CRANA set about being a part of the solu­tion. By March 1993, it could announce its two-year ​‘Locum Sup­port and Relief Pilot Project’, which it would deliv­er in part­ner­ship with the Penin­su­la and Tor­res Strait Region­al Health Authority.

Draw­ing on Gov­ern­ment fund­ing and coor­di­nat­ed by CRANA’s Mar­garet Daw­son (who had been CRANA’s first sec­re­tary), the project involved four expe­ri­enced RANs work­ing as locums, reliev­ing RANs in the field and seek­ing to embed a pri­ma­ry health care philosophy.

The RANs who had been relieved would head to Cairns, where they could then attend pro­fes­sion­al devel­op­ment and cross-cul­tur­al aware­ness work­shops, or sim­ply take some time out, util­is­ing fur­nished rooms in town.

The project had many facets, among them the pro­vi­sion of a 24-hour, tele­phone-based coun­selling ser­vice for RANs. This detail, blend­ing in though it did, would ulti­mate­ly prove to be the project’s last­ing legacy.

Build­ing up to the Bush Cri­sis Line

In 1994, the remote area nurs­ing work­force suf­fered a series of rever­sals. The Locum Sup­port and Relief Pilot Project was not re-fund­ed or expand­ed. CRANA’s sec­re­tari­at fund­ing itself appeared to be at risk of non-renew­al. 21-year-old nurse San­dra Hoare was also trag­i­cal­ly mur­dered in out­back New South Wales.

CRANA kept in the fight. By 1995, the not-for-prof­it had man­aged to extend its sec­re­tari­at fund­ing arrange­ment, and Sal­ly John­son was induct­ed as a Mem­ber of the Order of Aus­tralia for her con­tri­bu­tion to remote area nurs­ing and Abo­rig­i­nal health in a move that seemed to point to wider recog­ni­tion of RAN practice.³

This year also saw the pub­li­ca­tion of the Con­text of Silence report which includ­ed Janie Smith, then EO, and Jen­ny Klotz among the research team. The report set down on paper the real­i­ty of occu­pa­tion­al violence.

It found that RANs were liv­ing with fre­quent threats to their per­son­al safe­ty while on and off call and duty, and that a major­i­ty did not feel ade­quate­ly pre­pared for their cur­rent work. A quar­ter of respon­dents were the only health pro­fes­sion­als in their com­mu­ni­ty; a third no longer felt con­fi­dent in report­ing vio­lent inci­dents to their employ­ers based on pre­vi­ous report­ing expe­ri­ences; over a third were in fear of their per­son­al safe­ty; and more than half had no access to a secu­ri­ty escort when on call.⁴

The real­i­ty faced by RANs could no longer be denied, and there was a sud­den urgency to the report’s rec­om­men­da­tions, which includ­ed the following:

Fed­er­al, State and Ter­ri­to­ry Gov­ern­ment and employ­ing bod­ies… devel­op for­mal and infor­mal mech­a­nisms to pro­vide appro­pri­ate and ade­quate 24-hour debrief­ing and post-trau­ma ser­vices for RANs and oth­er health staff.

The sup­port line asso­ci­at­ed with the Locum Sup­port and Relief Pilot Project had con­tin­ued even after the project ter­mi­nat­ed, but on skele­ton fund­ing. Dur­ing this phase it was up to the Exec­u­tive Offi­cer, not a trained psy­chol­o­gist, to answer these calls and pro­vide support.

This all changed when the Bush Cri­sis Line was fund­ed to com­mence in 1997 by the Office of Abo­rig­i­nal and Tor­res Strait Islander Health Ser­vices. It was offi­cial­ly launched at the Launce­s­ton con­fer­ence of that year. CRANA began pro­mot­ing the ser­vice and rapid­ly dis­trib­uted 1,000 fridge mag­nets, 8,000 tele­phone stick­ers, and 3,500 flyers.

The need for the ser­vice quick­ly made itself appar­ent. Dur­ing the first six years, the ser­vice pro­vid­ed over 1,500 hours of coun­selling, across more than 2,000 calls and deliv­ered well­be­ing work­shops in the likes of Bro­ken Hill, Cook­town and Alice Springs.

The line would sub­se­quent­ly be rebrand­ed to the Bush Sup­port Line in the ear­ly 2000s, in recog­ni­tion of the fact peo­ple can and should access help before they reach cri­sis point. It con­tin­ues to this day.

Safe­ty and security

The ful­fil­ment of the 24-hour sup­port rec­om­men­da­tion was not the Con­text of Silence report’s only lega­cy. It also played a hand in pro­pelling fund­ing for CRANA’s edu­ca­tion­al offer­ings, reduc­ing sin­gle-nurse posts, improv­ing accom­mo­da­tion and facil­i­ty safe­ty, and shap­ing employ­er attitudes.

How­ev­er, in 2016, any sense of progress came to a halt with the trag­ic mur­der of well-respect­ed and ded­i­cat­ed remote area nurse Gayle Wood­ford in Fre­gon, South Aus­tralia. Janie Smith was pres­i­dent of CRANAplus at the time.

“The whole remote work­force was griev­ing and there were peo­ple who were so angry and who feared their safe­ty and start­ed leav­ing remote areas,” she recalls. ​“It was an unset­tling time for the whole remote workforce.”

In the wake of the tragedy, the sec­tor began to crit­i­cal­ly reflect on its long-held prac­tices and chal­lenge its accep­tance of risks that were rou­tine­ly con­sid­ered ​‘just part of the job’.

CRANA rep­re­sen­ta­tives trav­elled to Can­ber­ra for a round­table with Fiona Nash, then Min­is­ter for Rur­al Health. In-line with its long-term pol­i­cy, CRANA mount­ed calls that RANs should not go out on call by them­selves, but always be accom­pa­nied by anoth­er person.

CRANAplus soon received fund­ing from the Com­mon­wealth Depart­ment of Health to under­take the Remote Area Work­force Safe­ty and Secu­ri­ty Project. It con­sult­ed exten­sive­ly with the work­force and con­vened an expert advi­so­ry group con­tain­ing senior nurs­ing rep­re­sen­ta­tives from around the coun­try, and pub­lished Safe­ty and Secu­ri­ty Guide­lines for Remote and Iso­lat­ed Health, the Work­ing Safe in Remote and Iso­lat­ed Health Hand­book, a risk assess­ment tool and var­i­ous train­ing materials.⁵

Flinders Uni­ver­si­ty and CRANAplus also ini­ti­at­ed the Gayle Wood­ford Memo­r­i­al Schol­ar­ship in mem­o­ry of Gayle.

In 2019, the SA Gov­ern­ment intro­duced new leg­is­la­tion known as Gayle’s Law, that states health prac­ti­tion­ers in remote areas of South Aus­tralia must be accom­pa­nied by a sec­ond respon­der when attend­ing an out of hours or unsched­uled call­out. How­ev­er, there is still much work to be done, includ­ing the full nation­al imple­men­ta­tion of an ​‘Always Accom­pa­nied’ approach to practice.

Diver­si­fi­ca­tion

CRANA’s biggest growth spurt may have occurred in the late 1990s, but a sec­ond spurt fol­lowed in 2008.

CRANA was in name an organ­i­sa­tion for remote area nurs­es, but actions speak loud­er than words, and they sug­gest­ed that CRANA rep­re­sent­ed the entire remote health work­force. For exam­ple, health pro­fes­sion­als from many dis­ci­plines taught, and were taught, on its courses.

CRANA found itself in a posi­tion where its name did not reflect its activ­i­ties, nor its con­sti­tu­tion its ambi­tions.

As Janie Smith put it at the time, ​“While being ​‘a nurse’ and being ​‘reg­is­tered’ may have been the ​‘ide­al’ 25 years ago when CRANA was estab­lished [these con­sti­tu­tion­al require­ments] no longer [reflect] the real­i­ties of the cur­rent work­force envi­ron­ment, the mul­ti­dis­ci­pli­nary nature of remote work and the nation­al push towards a more inter­pro­fes­sion­al prac­tice”.

This, and the need to be ​‘remote’ (which left out iso­lat­ed pro­fes­sion­als), was result­ing in the exclu­sion of health pro­fes­sion­als who oth­er­wise sub­scribed to the cause.⁶

“This was when CRANA was sit­ting in Alice Springs in this gor­geous lit­tle rock build­ing,” Janie Smith says of the Bath Street head office CRANA had at the time.

​“CRANA was like a lit­tle cot­tage indus­try, doing its thing, strug­gling for fund­ing. It was at the stage of need­ing to move itself into more of a cor­po­rate enti­ty. It was tee­ter­ing on being some­thing big­ger. There was huge poten­tial to expand and gov­ern­ment good will to make that happen.”

CRANA decid­ed it was time to make the bold move. Under Pres­i­dent Chris Cliffe and CEO Car­ole Tay­lor, the organ­i­sa­tion incor­po­rat­ed itself in the NT in 2008 to become ​‘CRANAplus’, and tran­si­tioned from a remote-area-nurse-only organ­i­sa­tion to one that wel­comed a wider Mem­ber­ship and rep­re­sent­ed all peo­ple work­ing in and for the health indus­try in remote Australia

With­in two years, around 14% of CRANA’s Mem­bers were para­medics, doc­tors, Abo­rig­i­nal health work­ers, and oth­er non-nurs­ing health professionals.

Ongo­ing growth

CRANAplus has con­tin­ued to mature and diver­si­fy fol­low­ing this impor­tant con­sti­tu­tion­al change. It opened an office in Ade­laide in 2008 and in Cairns in 2012; the lat­ter became the head office short­ly there­after. In 2013, it took on its first Patron, human rights expert and For­mer Jus­tice of the High Court of Aus­tralia, Michael Kirby.

Mem­ber­ship struc­tures have changed over the years. In the begin­ning, CRANA had state rep­re­sen­ta­tives who report­ed back to CRANA on key issues and sought to grow Mem­ber­ship in their state. This con­nec­tion with the grass­roots per­sists in the mod­ern day through the CRANAplus’ Nurs­ing and Mid­wifery Round­table, as well as the annu­al Mem­ber Survey.

Thanks to the his­to­ry doc­u­ment­ed here, CRANAplus has estab­lished itself as a well-respect­ed author­i­ty on remote health. Gov­ern­ments, health ser­vices, Pri­ma­ry Health Net­works, rur­al work­force agen­cies, uni­ver­si­ties, com­mit­tees and steer­ing groups val­ue its collaboration.

Despite its 40 years, CRANAplus still has the quick reflex­es that enabled its rapid response to the Inter­ven­tion. Per­haps two of the most sig­nif­i­cant nation­al events of recent years have been COVID-19 and bush­fires, and CRANAplus has been involved in both the COVID-19 Clin­i­cal Evi­dence Task­force and the deliv­ery of work­shops and resources for health pro­fes­sion­als in drought and bush­fire-affect­ed areas.

Mul­ti­ple land­marks in CRANAplus’ jour­ney walk­ing along­side Abo­rig­i­nal and Tor­res Strait Islander Peo­ples demon­strate its progress. In the ear­ly 1990s, CRANA’s Toni Dowd and Sal­ly John­son were involved in the devel­op­ment of Binang Goonj, a sem­i­nal cross-cul­tur­al edu­ca­tion­al mod­el that is still influ­en­tial today.

CRANA was a fierce advo­cate for Con­gress of Abo­rig­i­nal and Tor­res Strait Islander Nurs­es (now CATSI­NaM) in its ear­ly years, and the two organ­i­sa­tions con­tin­ue to collaborate.

In 2008, Bun­jalung woman Jo Appoo was the first Abo­rig­i­nal appointee to CRANAplus’ Board of Direc­tors. In 2015, CRANAplus launched its first Rec­on­cil­i­a­tion Action Plan. This was fol­lowed in 2020 by its First Peo­ples’ Strat­e­gy, which has pro­vid­ed new ways to priv­i­lege and ampli­fy First Peo­ples’ voic­es as we move towards gen­uine rec­on­cil­i­a­tion and justice.

40 years on, CRANAplus’ sto­ry con­tin­ues to unfold. It remains a sto­ry of peo­ple, unit­ed in recog­ni­tion of their shared inter­ests and con­cerns, and the knowl­edge that their voic­es are stronger as one.

As Sabi­na Knight said dur­ing her pre­sen­ta­tion at the 40^th CRANAplus Con­fer­ence, ​“Some [peo­ple] have stayed a long time, oth­ers have had an intense and short expe­ri­ence, but each of those con­tri­bu­tions has been vital to the devel­op­ment of our organ­i­sa­tion, the pro­fes­sion and the remote health landscape”.

Which real­ly brings home one of CRANAplus’ best traits. The organ­i­sa­tion is not an abstract, anony­mous enti­ty. It’s the sum its peo­ple – its Board, its staff, its vol­un­teers and its Members.

And what bonds these peo­ple togeth­er into a com­mu­ni­ty is the desire to improve remote health, to give back to the pro­fes­sion, and the ques­tion: ​“what can I do to make a difference?”

RELIVE THE HISTORY

• Part 1: 1982 – 1985: CRANA’s Ori­gin Story
• Part 2: Prepar­ing the work­force: the push for education
• Part 3: The fight for iden­ti­ty: val­i­dat­ing RAN practice

Foot­notes

1. CRANAplus’ main­tains its vol­un­teer roots to this day. A pas­sion­ate group of over 130 vol­un­teer facil­i­ta­tors con­tin­ue in the spir­it of CRANA’s ear­ly vol­un­teers and make it pos­si­ble for the organ­i­sa­tion to deliv­er con­tex­tu­alised edu­ca­tion on a nation­al scale.
2. Addi­tion­al copies were avail­able for $1. The Fly­er would even­tu­al­ly become CRANAplus Magazine.
3. Order of Aus­tralia hon­ours are usu­al­ly bestowed ear­ly in the year, but CRANA nego­ti­at­ed for Sally’s investi­ture to occur at the Dar­win con­fer­ence. It has been said that this is the first time the Tiwi Islands flag (adopt­ed in July 1995) was flown on the mainland.
4. Fish­er, J., Brad­shaw, J., Cur­rie, B.A., Klotz, J., Robins, P., Reid Searl, K. and Smith, J. (1995), ​“Con­text of Silence”: vio­lence and the remote area nurse, Cen­tral Queens­land University.
5. Advi­so­ry group mem­bers includ­ed Geri Mal­one (Direc­tor Pro­fes­sion­al Ser­vices), Rod Menere (Project Offi­cer), and Christo­pher Cliffe (CEO), who had all had long­stand­ing involve­ment with CRANAplus.
6. These themes and quot­ed phras­es emerged in an organ­i­sa­tion­al eval­u­a­tion car­ried out by Janie Smith, through RhED Con­sult­ing, and pub­lished in 2008.