The NSWNMA has given MPs a set of proposals to improve the dire condition of rural and regional healthcare.

A NSWNMA submission to a state parliamentary inquiry into rural and regional healthcare says people outside of Sydney experience health outcomes “substantially poorer” than their Sydney counterparts.

“It is not acceptable that residents in the rest of NSW are provided with an inadequately resourced, substandard system of healthcare while metropolitan Sydney residents enjoy far superior access and outcomes,” the submission says.

The NSWNMA represents 35,000 nurses and midwives employed in Local Health Districts outside Sydney.

The submission says rural and regional members are concerned about poor healthcare, not only from a professional perspective.

Their concerns also flow from “a deep commitment to their community and the reality that they and their families are also reliant on a system they know is under-resourced.”

People living in regional, rural and remote parts of NSW have higher rates of coronary heart disease, stroke, chronic kidney disease, mental ill-health and diabetes, but less access to health services.

Their health services are characterised by poor staffing and skill mix, with nurses and midwives routinely working in isolation.

They have limited access to continuing education, rely on colleagues to provide unpaid on-call support, suffer from inadequate security and transport services, and lack of medical cover.

Changing population numbers cause fluctuations in demand for care in regional, rural and remote health services. These spikes in demand have implications for workload, staffing and patient safety.

Some health services are impacted by transient employment models such as fly-in, fly-out (FIFO) workers in the mining industry.

Similarly, large tourist events, festivals and “grey nomads” all rely on regional, rural and remote healthcare services.

Staffing is the number one issue

Staffing is the number one issue raised by NSWNMA members trying to deliver care in regional, rural and remote parts of NSW, the submission says.

“On a routine shift they are expected to care for more patients than they have capacity to attend to safely, and when emergencies arise, they are woefully unsupported.

“There is also limited access to a casual workforce, which means that it is difficult to replace nurses and midwives who require short-term leave.”

There are significant concerns about inappropriate skill mix, such as large numbers of new graduates working in high-risk areas with insufficient supervision and support, or assistants in nursing (AiNs) being used to replace RNs.

Many rural and remote services can only operate because staff provide on-call coverage in the event of emergencies.

This is almost always unpaid – a “flagrant breach” of Award entitlements, the submission says.

“If a service cannot operate without a reliable on-call roster, then this needs to be formalised and the cost of paying these allowances must be factored into operating costs.”

The submission says a nurse-hours-per-patient-day (NHPPD) staffing formula has been implemented in parts of the health system with good effect.

The submission recommends that NSW Health adopts the NSWNMA 2018 Ratios claim as the minimum nursing numbers required on each shift.

It also recommends that every aged care facility have a minimum of one RN on duty 24/7.

Burden of doctor shortage falls on nurses

The lack of on-site medical coverage puts “a huge burden of responsibility” on NSWNMA members, who experience widespread problems with accessing on-call and tele-health doctors.

The submission acknow-ledges that the virtual model of care is a necessity in circumstances where no medical coverage is available.

However, facilities that rely on virtual medical officer coverage must have the option of calling in an on-call RN who is within 15 minutes of the site, for support, it argues.

The submission notes that, while nurse/health managers are on call, they are often not physically available when needed in the emergency department (ED).

Also, unreliable internet coverage impedes access to clinical information systems, telehealth consultations and the delivery of safe, high-quality health care.

The submission recommends recruitment of more nurse practitioners to work in rural and regional areas, particularly at sites that rely on virtual medical officer coverage.

It says every ED open 24/7, regardless of how it is classified or described, should have at least three nursing staff rostered on duty, two of whom are qualified to attend to an acute emergency presentation.

Access to education difficult

Rural, regional and remote practice requires nurses to manage higher complexity interventions such as chemotherapy and dialysis while maintaining generalist skills, including “low frequency, high-risk clinical capability such as trauma response”, the submission says.

However, nurses find it difficult to access continuing education outside of metropolitan areas.

Most significantly, the degree of understaffing means that staff cannot be relieved to attend professional development opportunities.

Afraid to speak out

The NSWNMA submission to parliament’s rural health inquiry includes statements from members across the state.

These firsthand reports move beyond official statements and statistics by capturing the experiences of the people on the ground.

The submission says it is a fundamental principle of safety and quality in health care that individuals feel empowered to raise concerns about issues that impact on patient safety.

However, the submission says many contributors were worried about potential repercussions including “a punitive response from management” if they raised concerns.

This was despite the NSWNMA’s “assurances that advocacy is included in both the nursing and midwifery codes of conduct”.

For this reason, the submission does not identify individuals.