The state of affairs was sum­marised suc­cinct­ly in the Con­fer­ence Report:

“As the sole med­ical rep­re­sen­ta­tive in an iso­lat­ed com­mu­ni­ty, the remote area nurse requires extra skills and train­ing. Yet nurs­es arrive to begin with… lit­tle or no prepa­ra­tion for the sit­u­a­tion they will be encoun­ter­ing, both social­ly and pro­fes­sion­al­ly. At present there is no ade­quate pre-train­ing and only very lim­it­ed in-training.”

So began the task of con­vinc­ing the rest of Aus­tralia. In 1987 CRANA formed an edu­ca­tion com­mit­tee led by CRANA Mem­ber Mar­garet David­son, and by 1990 it had suc­ceed­ed in obtain­ing $16,000 for research into edu­ca­tion­al needs and relat­ed issues for RANs. Ann Kreger (CRANA’s first Assis­tant Trea­sur­er) took the post as project lead.

“Most pub­lished lit­er­a­ture to date reflects a roman­tic rather than a real­is­tic per­spec­tive of remote area nurs­ing,” she said at the 1990 CRANA con­fer­ence on the eve of the report’s pub­li­ca­tion. ​“There is a pauci­ty of research exam­in­ing remote area nurs­ing prac­tice and asso­ci­at­ed edu­ca­tion­al needs. Both are essen­tial for the devel­op­ment of a spe­cial­ist course for remote area nurses.”

The result­ing paper, Remote Area Nurs­ing Prac­tice: A Ques­tion of Edu­ca­tion, was released in 1991. The roman­tic notions Ann had spo­ken of were in pieces on the floor. 21 rec­om­men­da­tions rang out loud and clear, among them that:

• Devel­op­ment of remote area cours­es be done in a ratio­nal and nation­al­ly coor­di­nat­ed man­ner so that both the lim­it­ed mate­r­i­al and human resources can be utilised appro­pri­ate­ly and ensure good access…
• Short-term and long-term plan­ning of RAN edu­ca­tion cours­es be under­tak­en so that the needs of both hos­pi­tal-based and ter­tiary edu­cat­ed RNs are addressed.
• All cours­es for RANs either mul­ti-dis­ci­pli­nary or nurs­ing, be devel­oped in con­junc­tion with ter­tiary qual­i­fied RANs.

The plight faced by RANs had been stark­ly doc­u­ment­ed for one of the first times. It was a sober­ing moment, but also a moment of hope.

Mon­ey was cir­cu­lat­ing. That year, 1991, CRANA received fund­ing for its first Nation­al Sec­re­tari­at, allow­ing it to appoint a paid Exec­u­tive Offi­cer for the first time. The year before, the gov­ern­ment had ini­ti­at­ed the Rur­al Health Sup­port Edu­ca­tion and Train­ing (RHSET) Program.¹ Big things were in the off­ing for CRANA, but it would still be a while before the bud­ding organisation’s ambi­tions were realised.

Uni­ver­si­ty-based education

In the 1990s, uni­ver­si­ty-based under-grad­u­ate edu­ca­tion for nurs­es was still a devel­op­ing indus­try. Only in the pre­vi­ous decade had the Aus­tralian nurs­ing sec­tor com­menced its tran­si­tion from hos­pi­tal-based to uni­ver­si­ty-based edu­ca­tion, and it was not until the ear­ly 90s that the tran­si­tion had been com­plet­ed on a nation­al scale.

Through­out, and even before, this tran­si­tion, CRANA called for the devel­op­ment of a post­grad­u­ate course for remote health prac­tice. It would ulti­mate­ly col­lab­o­rate with Flinders Uni­ver­si­ty in the late 1990s to devel­op the post­grad­u­ate Remote Health Prac­tice Pro­gram, but this break­through fol­lowed a long and at times frus­trat­ing cam­paign for a post­grad­u­ate course.

In the ear­ly to mid 1990s, CRANA had con­sult­ed with uni­ver­si­ties on remote area health sub­jects, but nev­er an entire pro­gram. Resis­tance from acad­e­mia and the large­ly state-based fund­ing mod­el for nurs­ing edu­ca­tion act­ed as bar­ri­ers; as did the fact that CRANA took a no-non­sense approach to what nurs­es in remote areas were expect­ed to do. At times, this meant aim­ing to teach nec­es­sary skills that were ​“tech­ni­cal­ly illegal”.

In 1997, nation­al momen­tum swung in CRANA’s favour with the estab­lish­ment of Uni­ver­si­ty Depart­ments of Rur­al Health and the com­mence­ment of the Remote Area Nurs­ing Com­pe­ten­cies Project. This was a Gov­ern­ment-fund­ed project with CRANA rep­re­sen­ta­tion through Sal­ly John­son and Board Mem­ber and remote area nurse, Toni Dowd. It set in stone what such a post­grad­u­ate course for RANs should aspire to teach.

With­in this win­dow of oppor­tu­ni­ty, CRANA received finan­cial sup­port via the Office of Abo­rig­i­nal and Tor­res Strait Islander Health towards the devel­op­ment of the afore­men­tioned post­grad­u­ate Remote Health Prac­tice Pro­gram. Flinders Uni­ver­si­ty agreed to part­ner with CRANA and deliv­er the course. CRANA held a three-day stake-hold­er work­shop in Alice Springs in the spring of 1997 to devel­op the curriculum.

In a case of déjà vu, this Alice Springs based event blew all expec­ta­tions out of the water. Where 30 atten­dees were expect­ed, over 100 arrived – 25 of them from CRANA. Course devel­op­ment was a tri­umph of inter­pro­fes­sion­al­ism, with organ­i­sa­tions such as the Aus­tralian Col­lege of Rur­al and Remote Med­i­cine and Ser­vices for Aus­tralian Rur­al and Remote Allied Health involved.

Informed by this work­shop, the post-grad­u­ate course that CRANA had envi­sioned for so long sud­den­ly mate­ri­alised through Flinders University’s Remote Health Prac­tice pro­gram. Sue Lenthall, a remote area nurse who had recent­ly served as Exec­u­tive Offi­cer with CRANA, became the first course coor­di­na­tor. The pro­gram was head­quar­tered in the new­ly mint­ed Cen­tre for Remote Health (CRH) in Alice Springs, and in April 1999, Sue deliv­ered the first lec­ture there. As of 2023, the pro­gram has gone on to grad­u­ate hun­dreds of people.²

Clin­i­cal preparedness

CRANA also had a long­stand­ing vision of a course teach­ing advanced emer­gency skills and trau­ma man­age­ment. This idea would blos­som into the Remote Emer­gency Care (REC) course.

Up to this point, avail­able edu­ca­tion in remote emer­gency care was not fit-for-pur­pose. Few cours­es came out to rur­al and remote areas and those in urban Aus­tralia were time-con­sum­ing and cost­ly to access. They taught how to deliv­er care with­in a well-equipped team, with an ambu­lance and doc­tor close at hand, with­in and not across cul­tures. What remote health pro­fes­sion­als need­ed was a course that acknowl­edged their real­i­ty, and taught them how to find solu­tions with­in it with­out com­pro­mis­ing on qual­i­ty of care.

CRANA gained the boost it need­ed through RHSET fund­ing in 1997. After a peri­od of con­sul­ta­tion with con­sumers and health prac­ti­tion­ers to devel­op the cur­ricu­lum for this fledg­ling REC course (led by RN and lat­er Board Mem­ber, Kathryn Zeitz, and first REC coor­di­na­tor Geri Mal­one), CRANA hit the road in 1998 to deliv­er pilot cours­es in Alice Springs, Broome, Port Augus­ta and Thurs­day Island.

Edu­ca­tors lugged the man­nequins with them on small air­craft and ​“begged and bor­rowed” what they could to get the show on the road, but the cours­es were imme­di­ate­ly well-received, par­tic­u­lar­ly the hands-on skills sta­tions. More­over, par­tic­i­pants felt val­i­dat­ed. Here was proof that their role was unique­ly chal­leng­ing and in need of a spe­cialised course. More than 15 years had passed since Sal­ly John­son and Jen­ny Klotz had writ­ten the orig­i­nal skills list in 1982, but CRANA’s per­sis­tence had final­ly paid of.

With­in no time, CRANA sensed the need for a Mater­ni­ty Emer­gency Care (MEC) course. In the ear­ly 2000s, Mem­bers fed back that they felt under­pre­pared for the mater­ni­ty emer­gen­cies they reg­u­lar­ly had to attend. It often fell to RANs and Abo­rig­i­nal Health Work­ers (AHWs) to deliv­er these ser­vices in the absence of res­i­dent mid­wives or doc­tors. This knowl­edge didn’t fall from the sky.

CRANA applied for a grant in 2001 to devel­op its MEC course. Fol­low­ing devel­op­ment by Geri Mal­one, Sue Kildea, Sue Kruske and Ree Dunn among oth­ers, the first Mater­ni­ty Emer­gency Care course was deliv­ered in April 2003 and imme­di­ate­ly, par­tic­i­pants report­ed feel­ing more con­fi­dent around child­bear­ing women and bet­ter able to under­stand mater­ni­ty conditions.

Despite its suc­cess, the course was not with­out well-mean­ing oppo­si­tion. Some felt it aimed to teach non-mid­wives rou­tine ante­na­tal care. It was nec­es­sary for CRANA to clear­ly define the course’s pur­pos­es and lim­i­ta­tions.
To quote from a 2006 paper on the devel­op­ment of the MEC³ the course is ​“Not intend­ed to pro­mote the deliv­ery of com­pre­hen­sive ante­na­tal care by RANs and AHWs. Rather it is to encour­age them to be alert, so preg­nan­cies are diag­nosed ear­li­er and screen­ing, care and ser­vices are offered as soon as pos­si­ble, with the woman then referred to appro­pri­ate­ly skilled providers.”

In the 2003/2004 finan­cial year, CRANA deliv­ered 13 cours­es to 278 par­tic­i­pants. By 2013, CRANAplus was deliv­er­ing 90 cours­es in the cal­en­dar year.

The growth can be account­ed for in a few ways. Through­out the years, increas­es in fund­ing and the growth of an incred­i­bly gen­er­ous and skilled pool of vol­un­teer facil­i­ta­tors have increased CRANAplus’ abil­i­ty to deliv­er an ambi­tious nation­al schedule.⁴ CRANAplus has con­tin­ued to devel­op new cours­es in response to emerg­ing work­force needs. The launch of its online learn­ing por­tal in 2010 helped to fur­ther bridge the tyran­ny of distance.

Health ser­vices through­out Aus­tralia have increas­ing­ly embed­ded CRANAplus’ cours­es with­in their onboard­ing and ongo­ing pro­fes­sion­al devel­op­ment process­es. The organisation’s nation­al rel­e­vance and the trans­fer­abil­i­ty of train­ing from state to state increased with the estab­lish­ment of the Nation­al Reg­is­tra­tion and Accred­i­ta­tion Scheme (NRAS) in 2010 and when CRANA became a reg­is­tered train­ing organ­i­sa­tion in 2013.

Clin­i­cal Pro­ce­dures Manual

There was still one final jew­el to insert into the crown of CRANA’s edu­ca­tion­al achieve­ments.

By the late 1990s, the Queens­land Pri­ma­ry Clin­i­cal Care Man­u­al (PCCM) and Cen­tral Aus­tralian Rur­al Prac­ti­tion­ers Asso­ci­a­tion (CARPA) Stan­dard Treat­ment Pro­to­col Man­u­al had suc­cess­ful­ly estab­lished best prac­tice in the treat­ment of com­mon clin­i­cal sit­u­a­tions. It was a use­ful ​‘what to do’ guide but there was not an equiv­a­lent ​‘how to do it’ resource for the clin­i­cal pro­ce­dures that were part of these stan­dard treat­ments, and so there arose a call for a com­pan­ion manual.

CRANA suc­cess­ful­ly applied for a RHSET grant to devel­op the man­u­al in 1999. A com­mit­tee chaired by Sabi­na Knight was appoint­ed and it set about devel­op­ing a con­cise, jar­gon-free, cul­tur­al­ly sen­si­tive man­u­al with a prac­ti­cal design and layout.

The first nation­al clin­i­cal pro­ce­dure man­u­al ever writ­ten for rur­al and remote health prac­ti­tion­ers con­tained 300 pro­ce­dures and 500 illus­tra­tions, and an over­whelm­ing 500 copies were dis­trib­uted in the first few weeks.
From the out­set, the Clin­i­cal Pro­ce­dures Man­u­al was inter­twined with the CARPA Man­u­al. There­fore, over time, it was decid­ed that the man­u­als would be edit­ed in tan­dem. CRANAplus has main­tained its involve­ment by active­ly par­tic­i­pat­ing in the manual’s gov­er­nance and edi­to­r­i­al com­mit­tees. To this day, the man­u­als assist prac­ti­tion­ers to com­pe­ten­cy and con­fi­dent­ly car­ry out clin­i­cal procedures.

CON­TIN­UE THE HISTORY

• Part 1: 1982 – 1985: CRANA’s Ori­gin Story
• Part 3: The fight for iden­ti­ty: val­i­dat­ing RAN practice
• Part 4: From cot­tage indus­try to cor­po­rate enti­ty (includ­ing the for­ma­tion of the Bush Sup­port Line)

Foot­notes

1. This pro­gram aimed to fund the devel­op­ment and tri­al of new ways to pro­vide health ser­vices, focus­ing on edu­ca­tion­al oppor­tu­ni­ties and sup­port for remote and rur­al health work­ers. It would allo­cate close to $37 mil­lion over the next decade, accord­ing to Har­vey, D., Webb-Pull­man, J. and Strass­er, R. (1999), Rur­al Health Sup­port, Edu­ca­tion and Train­ing Pro­gram (RHSET): Where to now? Aus­tralian Jour­nal of Rur­al Health, 7: 240 – 248.
2. CRANA also had an Edu­ca­tion and Research Offi­cer role based at CRH in the 2000s. This expand­ed CRANA’s aca­d­e­m­ic influ­ence and saw the organ­i­sa­tion active­ly involved in research into the remote health workforce.
3. Kildea, S., Kruske, S. and Bow­ell, L. (2006), Mater­ni­ty emer­gency care: Short course in mater­ni­ty emer­gen­cies for remote area health staff with no mid­wifery qual­i­fi­ca­tions, Aus­tralian Jour­nal of Rur­al Health, 14: 111 – 115.
4. At times it has even become an ​‘inter­na­tion­al sched­ule’. For exam­ple, CRANA deliv­ered cours­es in PNG in 2006.