Part A: Framing a research question
When searching the literature on Remote Area Nurses (RAN’s) there has been much research on the effects they have on Indigenous health, nurse burnout, stress, violence in the workplace and workplace retention, there is much written and researched about the effects of adverse social determinants on Indigenous health including remoteness, poor living conditions, lack of fresh quality food, poor housing and sanitary conditions, but almost nothing on the health of the individual RAN who faces similar living and working conditions as well as the social determinants of health as the population they are caring for. “Social determinants of health are the social and environmental conditions in which people live and work” (World Health Organisation, 2007, p1). Some of the major social determinants of health include (SACOSS, 2008),
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Healthy living conditions such as access to food, water, sanitation and accommodation
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Education, literacy and health literacy
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Stress
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Early life
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Social exclusion
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Employment and unemployment
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Age, sex and hereditary factors
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Culture, racism and discrimination
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Access to information and appropriate health care
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Social supports and access to transport
There appears to be a gap in the literature in addressing the health of RAN’s and how living and working in remote communities affects them and their health. There is little information on whether or not a RAN working long term in a remote community may face the same health problems as those they look after. Thinking about this I began to wonder if the social determinants of health that so adversely affect the health of Aboriginal populations living on remote communities would also impact on others that live there such as nurses.
I have included the PICO worksheet and search strategy below in order to outline and define my research question.
1. Define your question using PICO by identifying: Problem, Intervention, Comparison Group and Outcomes.
Your question should be used to help establish your search strategy.
Patient/Problem_______Remote Area Nurses in Australia_________________________
Intervention__________Social determinants of health_________________________
Comparison_______Health status of Remote Area Nurses____________________________
Outcome__________The effects social determinants have on Remote Area Nurses health________________________
Write out your Question: ____What are the effects of the social determinants of health on Remote Area Nurses in Australia?_________________________________________________
2. Type of question/problem:
Circle one: Therapy/Prevention Diagnosis Etiology Prognosis
Human Interest
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3. Type of study (Publication Type) to include in the search: Check all that apply:
Meta-Analysis ❏
Systematic Review ❏
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Randomized Controlled Trial ❏
Cohort Study ❏ Case Control Study ❏ Case series or Case Report ❏
Editorials, Letters, Opinions ❏ Animal Research ❏ In Vitro/Lab Research ❏
Qualitative ❏
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4. List main topics and alternate terms from your PICO question that can be used for your search
List your inclusion criteria – gender, age, year of publication, language
In this research question Remote Area Nurses (RAN’s) will be surveyed – a RAN is classified as someone who works in remote Australia For the purpose of this research. The Rural and Remote and Metropolitan Areas (RRMA) classification considers a remote zone to have a population of 5000 or less.
Geographical location - There are also geographical criteria to help define remote areas (Strong, Trickett, Titulaer & Bhatia, 1998).
Gender and age are irrelevant, this study will focus on any nurses who live and work in remote Australia
Language – English
Year of publication – 1970 -2011, it is important to look back and see if there have been any changes to Remote area nursing and the working and living conditions and role that the nurses perform.
Search terms include – RAN, social determinants, health, ill health, remote, Australia, aboriginal communities
List irrelevant terms that you may want to exclude in your search
Hospital, wards,
5. List where you plan to search
Data bases including Medline, CINAHL, Cochrane, PubMed, Nursing Consult and Health Collection
Part B: Literature review
I have selected two research articles that touch on some issues faced by RAN’s but do not directly address any potential health issues that may be faced by individual RAN’s. There is a gap in the research that needs to be addressed.
Article one:
What stresses remote area nurses? Current Knowledge and future action
Author:
Lenthal, Wakerman, Opie, Dollard, Dunn, Knight, MacLeod & Watson (2009).
Article two
Concerns, satisfaction and retention of Canadian Community health nurses
Author:
Armstong-Stassen & Cameron (2005).
Overlapping concepts in each of these articles, highlight some of the issues faced by RAN’s
See appendix one for a full list of concepts from each article and those that overlap. Three concepts in particular will be explored in futher detail to show the reader how potential social determinants of health can indeed advesrsly impact on the health of the RAN.
Concept
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Author / year/ primary (P) or secondary(S) citations
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Impact of stress
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Lanthall, et al, 2009 (S); Armstrong-Stassen et al, 2005(S).
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Lack of support from management and social support
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Lanthall, et al, 2009 (P); Armstrong-Stassen et al, 2005 (S).
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Lack of adequate resources
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Lanthall, et al, 2009 (P); Armstrong-Stassen et al, 2005(P).
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The impact of stress on RAN’s can be related to demanding workloads, professional and social isolation, skill levels required, high mortality and morbidity rates and the considerable effort required to meet the job demands (Lenthall, et al, 2009). Other areas that can contribute towards stress in the workplace include lack of support, unclear roles, increase workloads and unreasonable expectations (Armstrong-Strassen & Cameron, 2005). The emotional and psychological distress caused by the job can also impact on the remote area and community nurse and contribute to increase stress levels and lead to potential burnout (Armsrong-Strassen, & Cameron, 2005). The Australian Medical Association (AMA), describes long term stress as damaging to health, stress can impact negatively on mentalhealth as well as contribute negatively to the body’s stress response causing harm to the cardiovascular and immune systems (AMA, 2007). Long term stress can cause infections, obesity, diabetes, hypertension, stroke and depression (AMA, 2007). The AMA (2007, p3) also lists “continuing anxiety, insecurity, social isolation and lack of control over work and home life” as stressors, all of which a RAN faces in her/his daily life.
Lack of support from management and lack of social support can impact negatively on aRAN’s health. Lenthall et al (2009) state that -
“Working in isolation is the most pervasive feature of remote area life. Isolation extends beyond geography to encompass social and professional life. In particular, the social support provided by family and friends is less accessible. This can increase the sense of personal and professional isolation”
Not having colleagues around to discuss cases, lack of communication and lack of support from management can impact on the sense of professional isolation (Armstrong-Strassen, et al, 2005). Social exclusion is identified as the lack of connection to the community in which a person lives, racism, discrimination, stigmatisation and unemployment can also contribute (AMA, 2007). A RAN may have different cultural and religious background to those they look after. living in a remotely for work may mean living many hundreds of kilometres away from extended family and long term friends. A lack of connectedness to family, friends and community is known as social interaction these can have negative impacts on physical and mental health (SASSOC). Social support and social relations have a positive impact onhealth and can even provide a buffer agent against health issues (AMA, 2007; SASSOC).
Much has been written regarding access Indigenous people have to health care in remote Australia. Lenthall et al, 2009; Armstrong-Strassen, Cameron , 2005, point out there is a lack of adequate funding, resources and training provided to RAN’s and community healthservices making it difficult for the nurses to do their jobs. The nurses who live on these communities have access to the same standard of health care as their clients, due to physical isolation such as floods and no staff to relieve them. Lack of funding and resources affect everyone that lives remotely, if the truck can’t get into the community with fruit and vegetables then everyone living in the community goes without including RAN’s.
Part C: Construction of an appropriate research methodology and method
Research design:
In order to answer the research question – What are the effects of the social determinants of health on Remote Area Nurses in Australia?
A qualititative method is best. Qualititative research is interested in human experience, values, consciousness and subjectivity (Taylor, et al, 2006). The methodology best suited to this question is Grounded Theory. Grounded Theory is ideal for topics/questions where not much is known and the researcher can start from the ‘ground’ up (Taylor et al, 2006). Grounded theory allows the researcher to use various modes of data collection such as interviews, the data is then compared and hypotheses are generated, problems and solutions can be identified using this theory (Taylor et al, 2006).
Participants:
RAN’s are defined by the RRMC and geographical criteria as above. Age and gender are irrelevant in this study. Each community falling in the above category will be contacted by phone initially and then a mail out will be sent to the community for nurses to participate in. As the participants won’t be identified by approaching CRANA or the Nurses RegistrationBoard this will help with confidentiality but may limit the participation of the recipients.
Research Setting
Due to the distances in Australia and the difficulty in accessing remote communities the researchers will choose one or two communities to visit to interview and observe the RAN and even practice nursing to experience the adversity’s first hand. The collection and dataanalyisi will be done at the researchers home town.
Data Collection
Data collection will be largely done by questionnaire mailed out to the participants with one or two observation placements to allow the researcher to talk and observe RAN’s and experience firsthand the adversities faced
Data Analysis
Qualitative data needs to be reviewed and maid ideas and themes need to be grouped, fromthese central ideas and theories will begin to emerge.
Ethical considerations
Ethical research is concerned with moral questions and behaviours during research, it has been put in place to ensure no harm comes to the participants (Taylor et al, 2006).
When pursing research it is important to obtain approval from a Human Research EthicsCommittee (Taylor et al, 2006). The Australian Nursing Federation and the National Health and Medical Research Council (NHMRC) have developed guidelines or codes for the standards for ethics and nursing research (Taylor et al, 2006). The nursing researcher should be familiar with these standards and codes and follow them to the letter to ensure ethical research has been carried out (Taylor et al, 2006). Below is a brief outline of issues to consider when undertaking ethical research
Specify any psychological and other risks to the participants
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While doing qualitative research that involves interviews and questionnaires that request details of personal life’s and the revelation on confidential information the researcher can cause the participant psychological and emotional harm, the questions/interviews may bring up distressing memories, force the participant to face thoughts and memories or draw conclusions that they may not wish to face or may not be ready to face (Taylor, et al, 2006).
What steps will be taken to ensure protection of the participant’s physical, social and psychological welfare? Will the participants be assured that they may withdrawal from the study at any time without fear of the consequences?
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Full disclosure of the research will be provided, informed consent and the assurance that the participant will remain confidential and have the right to withdrawal at any time with no consequences. This is essential to ethical research and is a requirement when providing information and obtaining consent (Taylor et al, 2006). The RAN’s will be provided with information and contact details of counselling services, (Bush Help Line) and organisations such as CARANA.
Will the aims of the study be communicated effectively to the participants? How will this be done?
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Full disclosure of information.
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Identity of the researcher;
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Purpose of the study
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Nature of the study;
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The right to refuse to participate, or withdrawal at anytime
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The responsibilities of the researcher
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Possible benefits of the study, risk or side effects
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Alternative treatments
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Measures taken to protect privacy
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Ensure anonymity and confidentiality. (Taylor et al, 2006, p101).
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The researcher will be providing the RAN’s with a plain language statement which is used to provide information such as listed above to the participants in a language they can understand.
What steps will be taken to ensure informed consent of the participants/guardians?
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Each RAN will also receive an informed consent form. The consent form will be developed outlining this particular research, how it will be conducted and the requirements of the participants. The RAN’s after reading all the information may simply choose not to participate. If they send their questionnaires back, as they are not identified on their questionnaires it will be difficult to remove their responses once submitted. This may limit participation .
Describes the measures which will be taken to ensure the confidentiality of the participants. If confidentiality is not ensured justify?
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Each RAN will not be asked to give out personal details that would identify them, although the questionnaire will ask for age, gender, work and education experiences to help see if there is a comparison between these factors and any ill health described.Returned consent forms will be separated from the questionnaires and storedseparately.
Explain how you intend to store and protect the confidentiality of the data
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Upon receiving the returned questionaries and the notes of the interviews and observations will be locked in a filing cabinet in the researcher’s offices
Check text book for further storage advise
Appendix one – Key concepts of each article
Article one:
What stresses remote area nurses? Current Knowledge and future action
Author
Key concepts
1.
Remote area nursing is characterised by geographical, social and professional isolation
2.
RAN’s provide many aspects of primary health care
3.
The context of RAN work is extremely demanding
4.
RAN’s experience increased levels of occupational stress
5.
High turn over rates
6.
Impact of stress on RAN’s
7.
Lack of funding and resources mean lack of accessible and acceptable standards of health care
8.
Job demands become stressors when RAN’s need to expand considerable effort in order to meet them
9.
Decrease social support
10.
Physical and emotional exhaustion caused by long working houirs and continous on-call, high level of skills needed to perform tasks requiured
11.
Cultural differences
12.
Poor management practices, lack of support provided by management who are often hundreds of kilometeres away
13.
Little or no orientation to a new work place
14.
Work place violence
15.
Established support services and high quality education services now being made readily available
16.
Limited literature on the effect of stressors on RAN’s
Article two
Concerns, satisfaction and retention of Canadian Community health nurses
Author
Key concepts
1.
Little research on community health nurses
2.
Increase number of clients
3.
Large case loads
4.
Complexity of care required
5.
Lack of adequate resources
6.
Physical danger/assault, unsafe working environment
7.
Psychological distress, emotional effects of the job
8.
Inadequate staffing
9.
Poor facilities
10.
Lack of equipment
11.
Working with vunneralbe families with many problems
12.
Inadequate resources to do the job
13.
Lack of support from management
14.
Lack of information and communication between management, staff and clients
15.
Unclear roles
16.
Lack of access to technology
17.
Increase workload demands
18.
Working conditions – time required to travel, car costs, isolation from agency base
19.
Adequate training needs provided
Many of these key concepts overlap
Articlae one
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Article two
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The context of RAN work is extremely demanding
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Complexity of care required
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RAN’s experience high levels of occupational stress
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Psychological distress – emotional effects of the job
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Impact of stress on the RAN
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Increase work load demands
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Lack of funding and resources means lack of accessible and acceptable standards of health care
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