“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

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:

“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

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

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.

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

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.

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.”

CON­TIN­UE THE HISTORY

• Part 1: 1982 – 1985: CRANA’s Ori­gin Story
• Part 2: Prepar­ing the work­force: the push for education
• Part 4: From cot­tage indus­try to cor­po­rate enti­ty (includ­ing the for­ma­tion of the Bush Sup­port Line)

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.