Christopher Moorhouse
RPN, RN, Dip.Teach, BEd, MEd, MA, FRCNA, MACE
ISBN Number: 0 86396 824 4
Adelaide University
Department of Clinical Nursing
Joan Durdin Oration
Paper Series Number 7
Chris Moorhouse grew up in the Australian bush. Some of the kids at his 12 student school in the Riverina in New South Wales rode horses to school. Later, in merino sheep stud country in the mid north of South Australia and in sheep and cattle station country near the Flinders Ranges, he dabbled widely in search of a calling. Perhaps it was suturing the cut leg of a horse, or castrating calves, or slaughtering sheep and getting to know the anatomy in fine detail, or perhaps assisting the evacuation of an injured stockman by Royal Flying Doctor Service that set him on the path to health care.
After high school at Scotch College, Adelaide he took the unusual and courageous step of going nursing. Coming from a long family tradition of missionaries in exotic and demanding parts of the world, he too wanted to make a contribution, perhaps even a difference.
Like young men wanting to serve their country at war a generation earlier, he gave a fictitious age to meet the criteria for entry to psychiatric nursing. He transferred to Royal Adelaide Hospital to take a second certificate, later working as Registered Nurse in most areas of the hospital before then teaching a year in each of the three years of the hospital certificate course. He then served for several years as Coordinator of the Advanced Nursing Course for new graduates. His book Registered Nurse: the first year of professional practice (1992) reflects research done at the end of that period.
As W K Kellogg Foundation Research Fellow, Michigan (1983-86) he worked in the Faculty of Health Sciences, McMaster University, home of problem-based learning and at the Centre for Criminology, Faculty of Law, University of Toronto. Pursuing his interests in comparative research and occupational sociology, he then worked as Senior Research Fellow, National Police Research Unit in Adelaide. He was involved at this time in the professional socialisation process for nurses, doctors, physiotherapists, teachers and police.
As Foundation Dean, Faculty of Health Sciences, La Trobe University, Bendigo (1987-96) he set in place a model of professional education for the health sciences based on core teaching and foundation units across the health professions. This reflects his longstanding commitment to contribute to the promotion of interdisciplinary and intersectoral collaboration in health care.
Professor Moorhouse has served on numerous hospital and university boards and state and federal government advisory committees. He recently completed a four-year term on the Federal Health Minister's Rural Health Advisory Committee having oversight of establishment of University Departments of Rural Health in each state and the Rural Health Support, Education and Training (RHSET) Program for funding innovative rural health initiatives.
He was a Foundation Member of both the Australian Council of Deans of Health Sciences and the Australian Council of Deans of Nursing. He has presented and/or published over 100 academic papers. His professional commitment is to the promotion of interdisciplinary and intersectoral collaboration in the interests of more comprehensive and coordinated consumer services. This is reflected in his work on Multidisciplinary Collaboration in Palliative Care in Rural Australia (2000).
Professor Moorhouse has held the Foundation Chair in Rural Health and Community Nursing at University of Tasmania since 1997. He leaves this year to pursue rural interests, to write and to continue selected advisory and consultancy work in rural and community services. His current 'book in progress' will help patients, clinicians, families and supporters to maximise achievement of potential following major neurological trauma, stroke, brain surgery and rehabilitation, topics he knows well having worked in those areas, and having in recent years been a consumer of their services.
The Adelaide University, Department of Clinical Nursing was established in 1995 in collaboration with Royal Adelaide Hospital.
The Department continues to thrive and grow meeting the needs of the health sector in providing high quality post graduate education to nurses in Australia and through its international teaching programs. Research output through higher degree courses and activities such as The Joanna Briggs Institute and Midwifery, are recognised for their high calibre and relevance to clinical practice. The success of these programs relies on the continued collaboration of the Department and the organisations that provide health care.
Clinical practice remains the major focus of all research and teaching programs, it is therefore fitting that the Department of Clinical Nursing host the Joan Durdin Oration that celebrates the practice of nursing.
RPN, RN, Dip.Teach, BEd, MEd, MA, FRCNA, MACE
Professor of Rural Health and Community Nursing
University of Tasmania
I regard Royal Adelaide Hospital as my professional home and I am delighted now to be back on home turf. Thank you for the invitation and for the opportunity to share some views on a small slice of this world we share. I will offer some thoughts on the health care and higher education bits of our world and on rural health and interdisciplinary collaboration.
On such occasions, not only are we allowed the privilege of a little reminiscence, it is expected! I have now passed the magic quarter-century as a nurse. Actually, I passed it five years ago, but enough of ancient history and precise detail. I am happy to accept the privilege of a little reflection and reminiscence about Royal Adelaide Hospital where I worked for ten years, five of them from an office in the School of Nursing overlooking Adelaide University, joint sponsor of this Oration.
Here I feel among friends, colleagues, mentors, people who have had a great influence on me and on thousands of nurses, doctors, physiotherapists, occupational therapists, social workers, dietitians, scientists, chaplains, administrators, technicians, cleaners, cooks and others who care. That is their unifying bond, these special people who work in health, they care for and about others.
When I was invited to consider accepting the honour of giving this Joan Durdin Oration 'on a topic of your choice' I was cognizant of the likely diversity of this audience and the impressive breath of wisdom and experience represented in it. How was I to say something useful without teaching grandma to suck eggs - or grandpa, for that matter, to be more politically correct and gender inclusive?
Should I attempt to trace the trajectory and the impact of the Transfer of Nurse Education to the Higher Education Sector in Australia (1994)? Having had various roles in that process, ultimately serving on the federal government's committee to review the transfer, I could do that. No! Important, but now over done and again in flux as the settled dust is stirred. Revisiting that issue can wait.
Clinical practice; yes. I'll go down that track. After thirty years' nursing I've now had my first experience on the other side of the fence - as a recipient of health care. I'll give an insider's perspective on stroke, brain surgery and rehabilitation. Having in 25 years never lost a day's work due to illness, I had a couple of strokes about six years ago. The second had me almost shuffling off my D.H.Lawencian mortal coil; lost a year of work while I learned to read and write and walk and talk. I could acknowledge and encourage those who do such work. No! Too close, too personal, an indulgence. Another year and you can read the book.
What I'll do, I decided, is indulge my love of the bush and rural life and country living. I'll push the barrow for rural health; and I'll splice in an injunction for health professionals to work a little more in collaboration and a little less in their safe, secure, separate bunkers. We'll come to that in a few minutes. First, a few remarks on the context, purpose and potential of the Joan Durdin Oration. Not this one particularly, but all of them, indeed of the very concept.
One of the great joys arising from my work at the interface between health care and education, is that as the years roll by, paths and fortunes overlap and intersect and our teachers can become our peers; our professional adversaries can become our friends; our bosses can become our mentors; and, as in postgraduate research supervision, our students can become our teachers. On rare occasions, we have an opportunity to reflect on those networks and on the influence of others on what is important. This is such an occasion.
I will share with you only one of my trepidations on this occasion. To be trotted out to reminisce a little means that one has either reached some venerable status - and I can't claim that - or that one has simply survived long enough to have become what my children call 'One of the old farts in the business.'
To the students in the audience: I offer you the reminder that when you graduate and take your place in the landscape of your chosen profession, you will be building on the work of those many thousands who preceded you. They may not have got it completely right, and you will find new ways to do things better, but remember that what your forebears achieved, has given you the solid foundations on which you now build.
This evening is an opportunity for each of us to remember those who have shaped and influenced our professional lives, our personal lives, our opinions and our values. But remembering and honouring does not mean merely clinging to their coat-tails but rather, riding proudly on their shoulders. From that vantage point we gain a clearer view from whence we came, and thus, of where we are going.
None of us wants to re-live the past, but if we forget it, or deny what was untoward about it, we are indeed destined to make the same kinds of mistakes again. At the risk of falling prey to assertions of political incorrectness or anarchic thinking I defer to Santayana's saying (attributed1905-6) that:
Those who cannot remember the past are condemned to repeat it.
This became Shirer's (1959) epigraph for Rise and Fall of the Third Reich. This injunction guided my stance in putting together these comments.
Some in this room tonight have had considerable influence on others in this place. How do we show our respect? How do we honour? How do we remember? There are many ways, and we each have our own ways and our own special things to remember. Let me share with you one such way: Pamela Spry, Director of Nursing at RAH, was my boss and my mentor 21 years ago when my daughter was born. It is no coincidence that her name is Pamela.
In nursing, as in the other health and caring professions, we actually get to make a positive difference to other people's lives. There are few greater privileges and the rewards can be considerable, but it is uniquely demanding work not suited to the faint-hearted or those in search of an easy ride. Most of us are part of a health care system under increasing pressure so such assertions need to be more than indulgent platitude or pious rhetoric. What can we do about it? How do we keep it an arena that attracts the talents, energy and fresh vision of young people? How do we move beyond platitudinous rhetoric?
The possibility of positing an hypothetical system-wide solution is beguiling, but as we speak, there are experts beavering away at related policy, practice, administrative and funding issues. Thus, my question, indeed my challenge for us tonight, is more simple, more addressable: What can you and I do to contribute on a practical, achievable, replicable, day to day basis? For instance: it helps a little to remind someone each day that what they have done is worthwhile, is appreciated and does make a difference. Such injunctions may not be rocket science but, as the old song goes: Little things mean a lot.
I learned much from Dr Durdin in my formative professional years in Adelaide. Much later, my own interest in history continues to be informed by her considerable and well-known contribution to the history of nursing, and history generally.
I commenced work at Royal Adelaide Hospital in 1973, following 3 years as a psychiatric nurse at the (then) Hillcrest Psychiatric Hospital where, as a green, naive kid from the bush, I grew up in a heck of a hurry. I pay respect tonight to my mentor Sybil McCulloch, Head of the School of Nursing at Royal Adelaide Hospital when I was cutting my teeth as an educator. She had the wisdom to recognise that it was not the idea that was critical - it may or may not have come to fruition - it was the longer term impact on future ideas. That is vision, that is confidence, that is clarity of purpose, that is breadth of perspective, that is thinking outside the envelope ... and that is the climate in which the young can grow, flourish and blossom.
How many potentially good initiatives wither on the vine for want of a little nourishment? Such nourishment and the challenges that mature resultant growth, were never in short supply at Royal Adelaide Hospital; and now it is forged in the crucible of informed intellectual debate and challenge, courtesy of the close links between this great Hospital and this great University.
Although I do not hold a degree from Adelaide University I developed considerable respect for what was then, and remains, a university committed to recognising and advancing the essential links between teaching, research and clinical practice. In the best of such organizations, there are seamless links between those elements of health care.
An example of the collaboration essential to such partnerships is the establishment in the 1970s of the Foundation for Multidisciplinary Education in Community Health (FMECH). In that innovative program students from nursing, medicine, physiotherapy, occupational therapy, social work and other professions took a subject specifically addressing the multidisciplinary nature and potential of community health.
The issues and imperatives are similar whether in health care, engineering, the law, science or the arts and humanities. Those who want to make a difference cannot do so by merely standing side by side at the barricades, or hunkered down in separate silos called disciplines or professions, but by collectively moving those barricades forward. It conjures romantic images the French Revolution, of the storming of the Bastille now popularly immortalised in Les Miserables. Slightly exaggerated imagery perhaps, but you get my drift: without people committed to a cause and defining it in ways congruent with the goals of most, there can be no revolution.
Such principles are evident in practice through the work of the Department of Clinical Nursing at the Adelaide University and I applaud that commitment; more-so because it is not easily attained and requires much more than vision and commitment. It must be managed into existence. In that regard, I acknowledge my friend and colleague, Alan Pearson and his colleagues. Alan was Australia's first Professor of Nursing and, until recently, Professor and Head of the Adelaide University Department of Clinical Nursing.
The thesis of my recent Bachelor of Nursing (Honours) student addressed Sudanese Women's Health (Wild, 1999). The research was borne of her own working the Sudan, but what set Alison apart was that she concurrently had an active and effective role in the international campaign to ban landmines. She put her research on hold to work with landmine victims in Africa - children learning to walk with one leg; fathers rebuilding destroyed homes with an arm blown off; mothers rebuilding fractured and war-ravaged families. Is this kind of aid work nursing practice? Is it legitimate nursing research? Some doubt it. I say, most assuredly it is! It is using nursing skills and insights, in tandem with personal insights, commitment and experience, to make a difference in the real world. To encourage such breadth and diversity requires us to think outside the envelope; to take risks, to encourage creativity and innovation.
During three years in United States and Canada one of the important lessons I learned, vicariously by looking over the shoulders of those who do what we do, was just how well we did health care in Australia. But we can only know that by putting ourselves to the test; and that only happens when our mindset allows us to acknowledge that, however well we might do it now, we might still graft into our practice something we learned from someone else. That requires humility, which can be a casualty of success.
The benefit and the raison d'etre of international exchange programs is that they enable people to look over the shoulders of others as they go about their business. Regrettably, they are less widely available than they were ten or so years ago. Australia's health care standards, and our contribution to others' health care, are the poorer for that. I encourage the bright, young, energetic, idealistic go-getters to hitch that energy and that commitment to whatever star will help them to grow, because in that process, they will contribute something to the growth and development of others, and thus the organizations and the professions they represent.
Recent international tragedies notwithstanding (the destruction of the New York towers and wars in Afghanistan and East Timor are but three examples) there has been a decline in the last decade or so in student and clinician exchange programs and overseas aid work. Individuals, organisations and the community, are the losers from this constriction in commitment and vision.
Some terms roll off the tongue so easily, don't they? Nice warm, fuzzy ideas, these. Cooperation, collaboration and care: surely they can be taken for granted where health professionals work? But how to make it happen? What stands in the way?
As a kid in a twelve student, one teacher, 'kindy to third year high' school in rural New South Wales I learned that you practise the piano and you see the doctor at his practice. Life was simple! We all knew our place and were secure in the knowledge of how it all fitted together. Much that we have held dear and taken for granted in nursing, as in other health professions, is being called into question, sometimes changed almost beyond recognition. Sometimes we mourn the loss of certainty and security of 'the way we were'. What does not change, what must not change, is the primacy of practice as the touchstone not only of nursing, but of all health care professions. But defining the limits of that practice, and defining who does what to whom under what circumstances, now that's a more complex challenge.
I am disturbed by an increasing reference to 'independent practice' as some kind of Holy Grail in nursing, as elsewhere. Wherever people practise a profession there is the need to work with others. The general medical practitioner work in relative independence, but can not possibly work independently in splendid isolation. He or she needs recourse to the surgeon, the physician, the physiotherapist, the community nurse, the domiciliary or home-visiting nurse, the pharmacist and others. In my view, too much emphasis is given to this notion of 'independent practice', and too little to the nature of the service that needs to be provided to offer optimal, or at least acceptable, health services in a community.
When I worked at Royal Adelaide Hospital team nursing was the in thing. We'd congregate in the team dressing room for the coach's pep talk; we'd identify our opponents and work out which way to kick the ball, when, where and to whom; we'd decide who would do the running, who would do the muscle work; who would keep the score, who would bring the drinks and who would kick the goals. We'd each have the game plan sketched out on bits of paper in our pockets. At 1.45 the whistle would blow, the ball would be bounced and we would all sprint into play.
That was teamwork. We all knew our place, we'd get dirty in the scrums, cheer at one another's achievements and commiserate with the missed goal. It was fun and we got the job done, albeit like a swarm of bees. But the hives are a lot smaller now; far fewer drones to do the hack-work; more to worry about. It's a different era for the health care game.
Interdisciplinary collaboration in health care is a thoroughly laudable principle. It is also too easy to glibly mouthed the platitude. Achieving it in more that superficial form takes time, effort, goodwill and patience. The benefits to the objectives of the organization and to the job satisfaction of those who work there, are considerable. The health service delivery benefits can be considerable, too.
At its worst, it is a foil, a cover for multi-skilling. The concept can be put into effect merely as a cover for getting more done with fewer people by extending the range of what each can be expected to achieve. I'm an advocate and a proponent for interdisciplinary collaboration in health care, but on the proviso that we have a shared and accurate sense of what is implied. Like the notion of the nurse practitioner, the words themselves can take on very different meanings and implications depending on the position of the canvasser of the idea in a given context. Multi-skilling, a laudable principle and a potentially attractive notion, is a conceptual close cousin of interdisciplinary collaboration. The problem is that it too neatly clouds and conceals the 'do more with less imperative'.
The health of populations living in remote and rural areas of Australia is worse than those living in capital cities and other metropolitan areas (AIHW 2000). Mortality and illness levels increase as the distance from metropolitan centres increases. Relatively poor access to health services, lower socio-economic status and employment levels, exposure to relatively harsher environments and occupational hazards contribute to and may explain most of these inequalities. Also, a large proportion of the population in the more remote parts of Australia are Aboriginal and Torres Strait islander peoples, who generally have poorer health status (AIHW 2000).
About 29% of the Australian population (including 64% of the Indigenous population) live in rural and remote Australia. 1998 Australian Bureau of Statistics SLA population estimates revealed the following population distribution:
| Metropolitan | ||
| Capital cities | 11,952,545 | 63.8% |
| Other metropolitan | 1,421,040 | 7.6% |
| Rural | ||
| Large centres | 1,119,312 | 6.0% |
| Small centres | 1,218,495 | 6.5% |
| Other rural areas | 2,466,695 | 13.2% |
| Remote | ||
| Remote centres | 224,168 | 1.2% |
| Other remote areas | 345,549 | 1.8% |
| Total | 18,747,804 | 100.0% |
Mortality and morbidity data indicate that the health of those in rural and remote areas is generally poorer in each of the National Health Priority Areas. The greatest differences for remote areas relative to metropolitan data are:
| Rheumatic heart disease: | mortality | 3 times higher |
| Hospital admission rates: | coronary heart disease | 1.4 times higher |
| 1.4 times higher | stroke males |
| 1.6 times higher | stroke females |
(DHAC & AIHW 1999)
Death rates for children under 15 years are higher with increasing remoteness, half these deaths being due to injury, other significant causes being motor vehicle accidents and drowning. Death rates for young adults (15-24 years) increase with increasing remoteness, death from motor vehicle accidents being three times more likely for young adults in remote areas compared with those living in capital cities. Young males from remote areas are almost twice as likely to commit suicide compared with young males from capital cities. The good news is that in the last decade injury death rates for young adults have fallen substantially, with motor vehicle accident death rates having decreased by 40%. The bad news is that rates of death by suicide have increased by 16% in the last decade.
Just as we have come to realise that Australia no longer rides on the fabled sheep's back, so we are coming to recognise, in the light of detail such as sketched out above, that the rural life is not as healthy and safe and idyllic as the romantic post-colonial dream of rural Australia would have had us believe. What is to be done about this emerging tragedy for our nation?
It is clear that these issues cannot be adequately addressed by short term, quick-fix solutions. These are not rural problems, they are public health problems for our nation. Fingers in leaking dykes and patches over regionally-specific trouble-spots, to keep politicians in their seats for the sake a few health program dollars, are no longer sufficient if Australia is to remain in the eyes of the world, a civilised country with a sophisticated health care system.
A rural youth suicide prevention program here, a farm injury prevention program there, a dam-drowning awareness program somewhere else: these are all worthwhile, appropriate and necessary initiatives, but they are insufficient. The challenge is in moving such programs from the 'pilot' phase to the 'national rural mainstreaming' phase. That requires more than political point-scoring and regional grand-standing. It requires a significant injection of support to those insufficiently resourced Commonwealth and State rural clinical services where strongly committed people struggle against an ebb tide to find recurrent financial support for program initiatives trialed, refined and ripe for broader implementation.
The provision of health care to people in the bush is beset by two principal factors:
The federal government has recognised the significance to our nation of providing reasonable health care to rural people, but platitudes are cheap. Getting services on the ground for rural residents is complex and expensive. While appropriate attention has been paid in recent years to recruiting and retaining rural doctors, equivalent systematic attention has barely commenced to address the aging and diminishing nursing labour-force in rural areas.
Be warned: we are not far from a nursing recruitment crisis in rural Australia. Some of my colleagues nursing in remote and rural areas, dealing daily with the consequences of unfilled vacancies, burn-out, and flagging of even the most robust rural commitment, are withdrawing while they have health intact. Such emergent service delivery problems are cutting deep furrows in the landscape of rural Australian health care.
For many metropolitan Australians, rural health care is symbolised by the Royal Flying Doctor Service. This uniquely Australian, world renowned rural people's 'mantle of safety' is, like so many rural services, under increasing pressure for its survival and continued service. The John Flynn Scholarship scheme is now well established as an incentive program to encourage medical students to take some of their clinical experience in rural areas. An equivalent, though very small program to encourage nurses to work in rural areas, is in its early stages. Why the differential in the recruitment effort for these two professions?
The Enhanced Primary Care Program released by the Commonwealth Government through the Royal Australian College of General Practitioners (June 2000) established Medicare Benefits Schedule items to support improved Health Assessment, Care Planning and Case Conferences on a multidisciplinary basis. The principle is laudable; its implementation is flawed. The professions listed as compensable under the scheme are:
The approved compensable health assessment, care planning and case conference items must involve the GP and at least two other health professionals. If we accept that a case conference, for instance, needs to involve at least three health professionals to assure reasonable client service, the paradox, indeed the flaw, is that such a case conference between a social worker, a specialist medical practitioner and a psychologist cannot reasonably (and compensibly) serve the interests of the client. Similarly, on the premise of the implementation pro-forma, an Aboriginal health worker, a nurse and an audiologist cannot usefully and cost-effectively contribute (compensably) to the care planning, assessment or case management of a client.
The strategic flaw in the implementation seems to be the implicit assumption that only the GP can hold it all together in the interest of a client. I know General Practitioners who work routinely and well with other health professionals from the above list. They would be happy in the interests of their patients and their communities, to have designated specialists from the list above, planning and arranging aspects of a person's overall and ongoing care, but the medico-centric policy in its implementation does not. This involves the GP in an additional commitment for variable contribution to client outcome. It is not a cost-effective scheme and seems unlikely to meet its intended objectives.
The availability and distribution of health services, equipment and facilities is part of the rural health problem now being addressed nationally. Two observations: first, without people to drive the expensive equipment and offer the services, whether bid-for or bestowed, the facilities and infrastructure, purchased with precious taxpayer dollars, can sit idle in hospitals and community health centres and clinics as dust-gathering curios. That's not hyperbole, some of us in this auditorium have seen it.
Second, such service initiatives require education and accredited programs to ensure that rural health professionals have requisite knowledge, skills and competencies specific to the demands of rural practice. Put crassly, it's not only about having enough Band-aids in rural communities, it's about making them available to those who need them, and having people in the communities who know how to use them to best effect.
Medical practitioners are not the only health professionals able to put on a Band-aid appropriately and skillfully. Is our taxpayer health care dollar being used in the most effective manner in rural health as currently structured? Is there some room for lateral thinking about the division of health care labour? Can some services be streamlined by re-casting who does what to whom in the rural health care delivery context? Yes. But to identify such possibilities and to trial, evaluate, refine and mainstream those things demonstrated to have greatest health service delivery efficacy, requires a vision of the possible and a commitment to improve access to health care for rural Australians. When the policy-makers, the funders and the health professionals have their eyes on the same ball, then there is a chance of creating and refining a service that better meets the health care needs of rural Australia. The health of rural Australians will be best served not by re-inventing the wheel; not even by making the wheel bigger - that costs money! It is about closely examining the spokes in that wheel to identify how each can more effectively carry an equitable share of the rural health burden.
Every nurse can recite the litany of care, tell tales about the primacy of care in their profession and proclaim theirs as the profession predicated on care, rather than cure. What does that signify in rural Australia?
Some important health services can be more cost-effectively offered by people other than doctors. Many of the rural doctors I know, who are facing significant and sometimes inappropriate and unnecessary demands on their time, could be done by other people; and that's what these rural GPs want. The key is having safe, cost-effective and responsive alternatives to the way health care is currently provided through general medical practice. This has been recognised, in part, by the new Medicare schedule enabling GPs to charge a Medicare-rebateable fee for services provided by nurses and allied health professionals employed by the practice.
The federal government, in the run down to this year's election made a serious error of strategic judgement in targeting one profession - medicine - as the solution to the rural health crisis. The 'More doctors = better services' part of the campaign was a serious strategic error for the government. Had it not been for the impact of world events deflecting attention from social and political issues in Australia the backlash from this inflammatory campaign edge would have been greater.
Health professionals who choose to work in the country have personal, rather than professional reasons for doing so. Usually, they just like, and have a commitment to, rural life and rural living. In professional terms, they pay a price for their choice to work in the bush. It is, for instance, difficult to get access to continuing education and professional development activities. This can have a cumulative impact on skill acquisition and confidence.
The major difficulty they have is getting release from their responsibilities to enable their absence for a day or so to attend educational and staff development opportunities. Incentive programs to encourage nurses and other health professionals to work in rural areas cost money. It has been found that the most effective mode is to get them there when they are students.
Rural Australia contributes to the nation's productivity, sustainability and wealth. Whether the rural produce is wool, wheat, fruit, timber, minerals or their associated secondary products, it is people that make it all happen; and people need health care. The health care available to families who live, or would prefer to live, in rural Australia depends on having state-funded and supported education, health and welfare services to attract and retain people to the rural areas. Without those resources and facilities, it is increasingly difficult to attract people to live and work in rural areas. It's a regressive spiral. There are many in public life and service and in the rural communities who are becoming very tired, even jaded, in their continued efforts to keep this great nation's rural areas alive and again vibrant. They need our support, encouragement and understanding. They don't want hand-outs or gratuitous charity. They do need people such as in this audience to have an accurate and informed understanding of the practical realities of survival in the bush; and we need to understand the national implications of failing to achieve this.
Whatever our nation does to retain its role as a major contributor to world primary production, it cannot achieve that without secondary services in those rural areas. Principal among those services are health and education, but banking, postal, local government, social, community and commercial services are also crucial. Yet we all know stories about the broader impact of the closure of these very services in country towns. The effect is cumulative, perhaps even exponential, rural community decay. Why? Because the issue is not only what happens when the rural doctor leaves town, it's also about the partner who may be a teacher available for employment in a rural school; and about three children who leave with them, perhaps reducing that school to below-viable enrollment; and what happens when the loved and long-serving Director of Nursing leaves a small rural hospital because the family has grown up and her husband, now ill, is no longer able to run the family farm and the children have made lives in bigger cities and yet those very rural services are eroding as we speak. Recent initiatives notwithstanding, there is much work yet to be done to attract young people to choose to spend some of their professional lives in rural areas.
There is a strong correlation between having grown up in the bush, and choosing to live and work in the bush. For that reason, efforts are now being directed at recruiting into the health professions students who have grown up in rural areas. The expectation is that they are more likely to choose to practice in rural areas.
The Commonwealth Undergraduate Remote and Rural Nursing Scholarship (CURRNS) Scheme (2001) is one of a range of Federal Government initiatives aimed at increasing the number of nurses living and working in remote and rural Australia. For many school leavers and students in remote and rural Australia, the lack of financial support can be a major obstacle to obtaining a university education. However, those students and school leavers interested in pursuing a career in remote and rural nursing can now be assisted through this national scheme to assist with accommodation, travel and living expenses incurred while studying at university.
The scholarships are worth $10,000 annually for each year of studies, up to a maximum of $30,000, and are available to remote and rural students undertaking undergraduate nursing at a tertiary level. There are 110 scholarships each year of which at least 10 are specifically designated forwarding to Aboriginal or Torres Strait Islander applicants. The Scheme is administered through Royal College of Nursing, Australia.
Recruitment of nurses to work in rural areas is a priority because there are too few even for the funded positions available. Retaining them in rural areas is equally important. The paradox is that, to retain them for too long contributes to the existing fact of an aging rural nursing workforce.
The Rural Health Stocktake (Best, 2000) predicted ongoing complexities for rural health, and especially for staffing to provide services. This becomes particularly apparent in light of an aging nursing labour-force. One of the consequent imperatives is for succession planning: nurses to replace those who retire or leave the rural areas for other reasons. Recommendations were made in relation to financial incentive, clinical nurse consultants for rural and remote Australia who work co-operatively with medical practitioners and who have the appropriate clinical skills to practise in settlements where there are no medical practitioners.
A third factor - succession planning - now needs to be added to this well-established priority list.
It has been a pleasure having you along on this quick inspection of the boundary fences. Basically, they are in sound shape. They were well constructed by our predecessors, but time and the winds of change take their toll. We have some work to do. Some of it we can do ourselves; some of it, we are negotiating with the fencing contractors. The long runs, the stony outcrops and the wash-aways need careful thought and close attention so that our repair efforts are not wasted. We are in this business for the long haul. The quick fix for appearance, or to make an impression, does no-one any good. If we do the job properly now, it will still be standing and doing its job, with minor maintenance, when the next generation of boundary riders comes to check on what we did and how well we did it. Some bits need replacing, a few holes to mend; and a couple of areas that need realignment and a re-think about where the boundary ought to be. We have had a quick look over the fence to check the condition of the stock on the other side - we don't get there much. Some of us are too busy tending our own little flocks; others of us are busy with board rooms and banks and merchandise warehouses and stock agents to see the detail.
But working out where the boundary fence should go, and what it should be made of and how high it should be, all depend on whether we want to keep the sheep in, the dingoes out; to impress the insurance company or the stock agent. But what I want to leave you with is the reminder that one of the most important parts of the boundary fence is the gate. That's how we can get next door to help the neighbour, to retrieve the straying beast, to borrow the prize bull and to travel beyond the boundaries to see what lies over the horizon.
Basically, this health care enterprise in which we share an interest is in reasonable shape. We have survived the drought though we still have severe stock shortages. It's taking a while to get the best crop rotations sorted and working out which wells hold water in the tough times and which ones can only be relied upon in a good season. But they are a tough breed, these rural nurses and the other health professionals who work with them. They are there for the long haul, but they need to know that Australia values what they do; and they need to pay more attention to letting Australia know just what it is that they do!
Thankyou, fellow boundary riders. The Billy has boiled. Come and join me for a brew and we'll yarn some more.
I dedicate this Oration to the memory of my father, Ron Moorhouse, from whom I learned the beauty of the bush and the love of rural life. I also learned that there is something to respect in almost everyone, but to hold no-one too much in awe, for even the great are subject to human frailties. Such diversity is both the nature and the wonder of the human condition.