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The History of CRANAplus (Part 3): The fight for identity — validating RAN practice

12 Dec 2023

How can you make your voice heard when you are out of sight from the majority of Australians? CRANA would answer this question successfully, but not without difficulty, over the next four decades. As Jenny Klotz put it in 1985, “The Tyranny of Distance is a daunting factor in trying to achieve any goals for an organisation such as CRANA.”

Not your every­day nursing.

How­ev­er, [dis­tance] is also our most saleable asset,” she con­tin­ued. Aside from the fact that the press at large is more inter­est­ed in the gore, hor­ror and extremes faced by Remote Area Nurs­es, I feel that we as an organ­i­sa­tion are just begin­ning to tap into a huge pub­lic and polit­i­cal empa­thy for the work we perform.”

To estab­lish this empa­thy for the pro­fes­sion, CRANA realised that it would need to devel­op a set of stan­dards out­lin­ing the unique skill set required by remote area nurs­es. Despite its efforts, it would some­times take a wide­ly pub­li­cised trau­mat­ic event to catal­yse change.

The need for standards

The emerg­ing RAN stan­dards need­ed to build in the prin­ci­ples of pri­ma­ry health care

While the cam­paign for edu­ca­tion was going on, a con­cur­rent cam­paign to devel­op remote area nurs­ing stan­dards was also underway.

Excel­lent work was being done by RANs but how could one know it was excel­lent work, with­out stan­dards? And if a RAN or a health ser­vice had room to grow, how could they assess them­selves and know what to aim for?

The issue was pro­nounced for RANs, who out­side of the CRANA con­fer­ence had lim­it­ed oppor­tu­ni­ty to inter­act with peers, mean­ing that even infor­mal’, socialised stan­dards were some­times missing.

In 1986, CRANA con­vened its first sub­com­mit­tee to devel­op stan­dards. Com­mit­tee con­ven­er, Angela Low, sum­marised the chal­lenges they faced:

CRANAplus Fel­low Sophie Heathcote.

How could nurs­es from such a diver­si­ty of back- grounds from Abo­rig­i­nal Com­mu­ni­ties of Arn­hem Land and the cen­tre, to com­pa­ny and prospec­tor min­ing towns, to the deserts of the cen­tre and the west and the snow fields of the south, and even the islands of the Indi­an Ocean, explain to the pro­fes­sion at large the ele­ments of their role they all instinc­tive­ly felt they had in com­mon. Fur­ther, how could they con­vince their col­leagues that despite this diver­si­ty they were a unique enti­ty that has spe­cial needs and respon­si­bil­i­ties which often, of neces­si­ty, went beyond the accept­ed bounds of nurs­ing practice?”

The sub­com­mit­tee felt a height­ened sense of urgency in the late 1980s. A young Eng­lish nurse, Sophie Heath­cote, had been sent to work in remote New South Wales. There was an inci­dent with a trag­ic out­come. A young man died. What fol­lowed includ­ed a series of inves­ti­ga­tions and inquiries, and Sophie was tem­porar­i­ly deregistered.

CRANA believed that Sophie had been unfair­ly made into a scape­goat and at the 1989 CRANA con­fer­ence, remote area nurs­es signed a peti­tion for Sophie’s cause. In 1990, CRANA pub­lished its first remote area nurs­ing stan­dards which includ­ed its famous state­ment on the phi­los­o­phy of remote area nurs­ing. In 1991, Sophie’s appeal was upheld. She was lat­er invit­ed to speak of her expe­ri­ence at the CRANA con­fer­ence¹. These two events marked a turn­ing point in the nation­al con­ver­sa­tion. Sud­den­ly, there was greater acknowl­edge­ment that RANs in the field were not being prop­er­ly pre­pared or supported.

Con­tin­u­ing to push for standards

Sabi­na Knight and Sandyl Kyr­i­azis busy on the advo­ca­cy trail in 1999.

Through­out the next decade, CRANA con­tin­ued to grow its rep­re­sen­ta­tion on com­mit­tees, includ­ing the bud­ding Nation­al Rur­al Health Alliance and the Aus­tralian Phar­ma­ceu­ti­cals Advi­so­ry Com­mit­tee. As stat­ed in a CRANA com­mu­niqué in 1996

Involve­ment in all of these groups marks a sig­nif­i­cant change in the pub­lic recog­ni­tion by leg­is­la­tors of the abil­i­ty of RANs to become involved in defin­ing the rights and scope of their prac­tice, if not self deter­min­ing in this regard.”

Thanks in part to CRANA’s ongo­ing advo­ca­cy, the Fed­er­al Gov­ern­ment invit­ed ten­ders to devel­op com­pe­ten­cy stan­dards for remote area nurs­ing in 1997. A team of researchers with strong CRANA rep­re­sen­ta­tion applied. Util­is­ing CRANA’s net­work, this group con­sult­ed wide­ly with RANs, con­sumers and oth­ers in the devel­op­ment of a nation­al­ly recog­nised set of com­pe­ten­cy stan­dards for RANs. They envi­sioned that these new com­pe­ten­cies, now fund­ed, nation­al­ly recog­nised, and con­sis­tent, would give CRANA great strength to argue for the devel­op­ment of accred­i­ta­tion cri­te­ria and cur­ric­u­la designed to enhance remote practice.

These two themes – accred­i­ta­tion and cur­ricu­lum devel­op­ment – define the lega­cy of the stan­dards. The results were fast and instan­ta­neous for cur­ricu­lum devel­op­ment, in the form of CRANA’s post­grad­u­ate and Remote Emer­gency Care cours­es. The jour­ney towards accred­i­ta­tion was to involve many more twists and turns, and is in many ways ongoing.

Advances and set­backs in recognition

John Wright and Fiona Wake in 2014 (both are cur­rent Board Members)

In 2003, CRANA ini­ti­at­ed its awards pro­gram, adding anoth­er string to its bow in the quest for pro­fes­sion­al recog­ni­tion. CRANA’s Fel­low­ship pro­gram was devel­oped with sim­i­lar goals in mind. Fel­lows were induct­ed to embody the stan­dards of remote health prac­tice and set an exam­ple in a large­ly self-reg­u­lat­ing industry.

CRANA imple­ment­ed ini­tia­tives like these with the ulti­mate goal of ensur­ing that nurs­es sent to remote areas were ade­quate­ly pre­pared so that they could deliv­er high-qual­i­ty, cul­tur­al­ly safe care.

How­ev­er, when the North­ern Ter­ri­to­ry Inter­ven­tion was announced in 2007, many feared that the progress made in this direc­tion would come undone.

The Inter­ven­tion fol­lowed the Lit­tle Chil­dren are Sacred Report and one of the mea­sures it was to involve was com­pul­so­ry child health checks. A fly-in, fly-out work­force, sep­a­rate to exist­ing pri­ma­ry health care arrange­ments, was to be cre­at­ed and include inter­state staff.

CRANA was approached to be involved in prepar­ing this work­force and it faced a chal­leng­ing decision.

Board Mem­ber Jo Appoo at a CRANAplus Meet and Greet in 2009 dur­ing the Intervention

Vic­ki Gordon

After dis­cussing the mat­ter with Abo­rig­i­nal Med­ical Ser­vices Alliance North­ern Ter­ri­to­ry (AMSANT), CRANA made the care­ful­ly con­trolled deci­sion to pro­ceed. As Pres­i­dent Christo­pher Cliffe wrote at the time, If
we are not involved then we would have no capac­i­ty to ensure that resources are appro­pri­ate and staff well prepared”.

Vic­ki Gor­don, a CRANA Board Mem­ber in the 1990s and Remote Sup­port Offi­cer at this point in time, rep­re­sent­ed CRANA in the coor­di­na­tion and deliv­ery of ori­en­ta­tion to staff in Alice Springs and Dar­win, work­ing along­side pae­di­a­tri­cian Dr Jim Thurley.

They were on the short­est of time­frames. Vic­ki began deliv­er­ing rapid brief­in­gs’ with­in nine work­ing days of the announce­ments. On day 10, the first Child Health Check Team was deployed. Vic­ki in turn con­duct­ed the debriefs with return­ing staff.

The Inter­ven­tion had a huge neg­a­tive impact on remote Abo­rig­i­nal peo­ple, but CRANA thought it’s hap­pen­ing and we need to make indi­vid­ual teams and peo­ple in com­mu­ni­ty as safe as pos­si­ble’,” Vic­ki reflects.

It wasn’t some­thing that CRANA would have ordi­nar­i­ly have done, but these were extra­or­di­nary times.”

Refresh­ing remote nurs­ing standards

Updat­ed stan­dards sought to include remote area nurs­ing in all its diver­si­ty, includ­ing mine site nursing

Cov­er of the RAN Cer­ti­fi­ca­tion booklet.

The Nation­al Reg­is­tra­tion and Accred­i­ta­tion Scheme was intro­duced in 2010. It aimed to ensure that all reg­is­tered health pro­fes­sion­als meet the same nation­al stan­dards, and to increase work­force mobil­i­ty between states and ter­ri­to­ries. The Inter­ven­tion was still front of mind for CRANA (by now known as CRANAplus), and sens­ing good will and oppor­tu­ni­ty for change, the organ­i­sa­tion reignit­ed its cam­paign for RAN standards.

Its own Remote Nation­al Stan­dards and Cre­den­tial­ing Project com­menced in 2012 and cul­mi­nat­ed in the endorse­ment of a new set of Pro­fes­sion­al Stan­dards of Remote Prac­tice: Nurs­ing and Mid­wifery. CRANAplus aspired to make these stan­dards user-friend­ly, con­tem­po­rary, and reflec­tive of the diverse prac­tice areas under the remote and iso­lat­ed banner.

Although then as now, nurs­es could be endorsed as Nurse Prac­ti­tion­ers in a spe­cial­ty rel­e­vant to remote prac­tice, endorse­ment for RAN prac­tice was not nation­al­ly con­sis­tent, avail­able or recog­nised (for exam­ple, Rur­al and Iso­lat­ed Prac­tice [Sched­uled Med­i­cine] endorse­ment was only avail­able to RNs in Vic­to­ria and Queens­land). There­fore, CRANA set out to estab­lish a nation­al­ly con­sis­tent cre­den­tial­ing process for the remote nurs­ing and mid­wifery work­force – the RAN Cer­ti­fi­ca­tion Pro­gram. This involved a self and peer assess­ment to con­firm that a remote area nurse met the min­i­mum essen­tial require­ments to be a safe provider of remote health care.

How­ev­er, as Angela Low from the Stan­dards Sub­com­mit­tee had intu­it­ed in 1990:

[The val­ue of stan­dards is] lim­it­ed unless employ­ers and employ­ing bod­ies acknowl­edge that they too have a role in main­tain­ing a pro­fes­sion­al stan­dard of remote area nurs­ing prac­tice.” CRANAplus pro­mot­ed its up-to-date stan­dards and engaged in con­ver­sa­tions nation­al­ly to encour­age employ­ers and juris­dic­tions to embed them.”

This cam­paign brought about sig­nif­i­cant local suc­cess­es, but over­all, its suc­cess was mixed.

CRANAplus does not cur­rent­ly offer the RAN Cer­ti­fi­ca­tion Pro­gram, but has been active­ly involved in the next chap­ter of remote area nurs­ing stan­dards. The organ­i­sa­tion recent­ly par­tic­i­pat­ed on the steer­ing com­mit­tee for The Nation­al Rur­al and Remote Nurs­ing Gen­er­al­ist Frame­work 2023 – 2027, con­vened by the Office of the Nation­al Rur­al Health Commissioner.

Mem­bers of the Steer­ing Com­mit­tee at the launch of the Frame­work at Par­lia­ment House, 2023.

This doc­u­ment describes the unique con­text of prac­tice and core capa­bil­i­ties for rur­al and remote RN prac­tice. As with the land­mark doc­u­ments that have gone before it, its poten­tial to bring about change is pal­pa­ble. In fact, the remote health sec­tor is poised at a crit­i­cal moment. The extent of imple­men­ta­tion is set to be the deci­sive factor.

The Frame­work pro­vides nurs­es with a tool for self-assess­ment, enabling them to work mean­ing­ful­ly with edu­ca­tors and men­tors to build their capa­bil­i­ties,” out­go­ing CEO Kather­ine Isbis­ter said in March.

Impor­tant­ly, the Frame­work is also a tool that employ­ers, edu­ca­tors, gov­ern­ments, and peak bod­ies can use to assess their cur rent pro­grams, con­sid­er scope of prac­tice and tai­lor their pro­fes­sion­al devel­op­ment oppor­tu­ni­ties. The Frame­work is a mean­ing­ful step towards a struc­tured and wide­ly avail­able remote area nurs­ing path­way, on par with the rur­al gen­er­al­ist path ways for med­i­cine and allied health.”

Foot­notes

  1. Sophie says that the fact that CRANA reached out and found me is some­thing that has always stayed in my heart” and that it inspired her Pres­i­den­cy of the Board in the 2000s. This gave her a plat­form to pro­mote the need for edu­ca­tion and prepa­ra­tion. She is now a CRANAplus Fellow.