July 3, 2022

rural and regional health

Nurses volunteer for West’s pandemic battle 

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Wearing PPE is uncomfortable at the best of times. The level of discomfort goes up a notch when you’re outdoors in hot weather and flies are crawling under your face shield.

Bush flies were among the challenges faced by Sydney nurse Lyn Whitlam when she joined the fight against COVID-19 in the outback town of Broken Hill.

Lyn, the branch Secretary and delegate at Ramsay Health Care’s North Shore Private Hospital, flew to the state’s Far West in response to an urgent call for volunteers.

“I wanted to do my bit to assist a very remote area of NSW that was struggling to deal with the pandemic,” she said.

Lyn was one of five nurses in the first Ramsay team to go to Broken Hill. She did an online COVID-19 vaccination course before starting her 10-day stint in late August.

She was seconded to the public health system and divided her time between an indoor vaccination centre and a drive-through testing clinic on Broken Hill Memorial Oval.

“At the testing clinic, I had my Ramsay uniform on with a thin blue apron, N95 respirator, face shield and gloves,” she said.

“It was hot, despite it being winter, and I expected someone to swallow a fly every time I asked them to open their mouth wide to obtain the throat swab.”

Not enough PPE

The out-of-town nurses helped move Broken Hill Hospital’s small immunisation clinic into the town’s civic centre, which enabled an expansion of the vaccination program.

The Sydney outbreak had been spreading for two months, yet Broken Hill could not supply enough PPE for the vaccination team, which typically comprised two nurses drawing up the vaccine, four vaccinating, two in the observation area, and a team leader.

“We had to ask Ramsay to send extra PPE, including N95 masks and face shields,” Lyn said.

“There were not enough computers and only one printer, and the internet was very poor.”

At the drive-through testing clinic, data collection was slow and error-prone due to a lack of computers and QR codes.

“The admin staff had to write down all the information – names, addresses, birth dates, Medicare numbers, etc. – then transfer it onto pathology forms, then hand the forms to me or another RN to do the tests. We would get the visitor to check the details and about 10 per cent of forms had incorrect information.

“All tests had to be sent back to Sydney for pathology and at one stage, we were told it was taking five days to get results back.”

During the weekend Lyn spent at the testing clinic it received only 148 visitors including locals, truck drivers and other motorists passing through town.

Serious communication issues

She says this partly reflects in-adequate COVID-19-related planning and publicity for the outback.

“There is a serious communication issue out west and people don’t have easy access to information,” Lyn said.

“A lot of locals are in a lower socio-economic group. They don’t have smart phones – they use flip phones or land lines – and don’t have computers. They can’t make appointments online and they can’t access their vaccination records.

“The local newspaper is now only available online and the town is in lockdown, so meeting places like pubs and clubs are closed.

“The word about testing and vaccination hasn’t been getting out. Very few of the local nurses had received their first dose of vaccine when we were there.”

Lyn has told Ramsay she’s happy to volunteer again at a vaccination or testing centre, including in Broken Hill.

“Hopefully they will move the testing centre indoors for summer, but I’d be taking a fly net just in case.”

Bring a cheque, Hazzard told

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Broken Hill Mayor Darriea Turley urged Health Minister Brad Hazzard to commit to more support for health services in the Far West when he made a flying visit to the region in September.

Cr Turley said local COVID-19 contact tracers were struggling to keep up.

Addressing Hazzard via ABC Radio, she said: “Please bring some relief for these staff. And please make sure you review essential travel, and you review regional travel.

“To come from a hotspot, two hotspots, and travel around – lovely of the minister, but please bring a cheque.”

Cr Turley later told a parliamentary inquiry that the spread of the virus in overcrowded housing in the Far West should have been planned for, given how well known the problem was.

She said decades of underfunding for health and housing services in Aboriginal communities had laid the groundwork for the crisis.

“The deep cuts to funding, the disrespect these communities are being shown, the lack of planning, has made them vulnerable,” she said.

Central Darling Shire administrator Bob Stewart told The Australian that the Wilcannia outbreak had “led to emergency management scrambling to find solutions to a long-term legacy issue”.

“It represents a massive failure of government over many years to address the basic human right of shelter, despite the warning signs contained in various reports and submissions,” Stewart said.

Understaffed rural hospitals brace for COVID-19

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COVID-19 is yet to infect the twin townships of Harden and Murrumburrah, but the local hospital already struggles to find enough nurses.

Nurses at Murrumburrah-Harden District Hospital, about 350 km south-west of Sydney, are in “a heightened state of preparedness” for any COVID-19 outbreak, says RN and clinical nurse educator Marilyn Wales.

“We conduct ‘desktop’ scenarios all the time,” Marilyn says. “What do you do if you get a potentially positive presentation, or a staff member develops symptoms? What do you do if you see a breach of PPE?”

“The reality is that COVID-19 is going to come out to small country hospitals like ours. Essential workers pass through our town all the time and stop for meals and fuel.”

An “essential worker” who visited Harden-Murrumburrah, population 2000, later produced a positive result but there was no local transmission.

Marilyn is secretary and delegate for the NSWNMA’s Harden branch. She shares ideas with NSWNMA members at hospitals across the state through fortnightly webinars and other teleconferencing.

“Every facility talks about staff shortages and inadequate skill mix and how hard it is to attract staff – especially experienced nurses – to small rural hospitals.

“Murrumburrah-Harden’s casual pool is very limited, and we often have difficulty engaging agency staff, partly because of COVID-19 restrictions.

“The nursing population is ageing and we are losing senior nurses who are FLECC (first line emergency care course) trained. That training gives us the ability to use the rural adult emergency care guidelines and administer certain drugs in the absence of a doctor.

“Senior nurses who leave are often replaced by RNs who have just completed their graduate year. They are put in charge of a hospital on weekends and nights with no doctor. That is just asking for trouble.”

Murrumburrah-Harden Hospital has nine acute beds and 20 residential aged care beds. It has a VMO on call.

Like many small sites, the RN in charge of the acute ward is also in charge of ED.

“If we had a respiratory presentation and had to isolate that person, it would take a staff member away for the entirety of that presentation,” Marilyn says.

“We don’t have the staff rostered on to manage that.

“If we get a COVID-19 case, one or more staff members may have to isolate for the required 14 days. If we take out two or three staff, we could be at service failure, because we don’t have the clinical staff resources to replace them.

“My heart broke when I heard that the department was thinking of fast-tracking students into hospitals. It’s an awful atmosphere to ask someone to start their career – in a pandemic.

“Students are already at risk of not being able to register with AHPRA (Australian Health Practitioner Regulation Agency) due to incomplete placements.

“Another government proposal was to bring back retired nurses. People retire for a reason and to bring them back and put their physical and mental health at risk is a big ask.

“Our Premier keeps saying our health system is coping. But staff are having to work 12- or 16-hour shifts and work on their RDOs.

“We might be coping at the moment, but we are not functioning in the proper manner, to the best of our abilities. For us to function we need to have enough staff with the required skills.”

Marilyn, who has nursed in Temora, Narrandera and Murrumburrah-Harden hospitals for 51 years, says she’s concerned for all nurses at this time.

“I’m especially concerned for the girls in Sydney. I cannot comprehend what some of them are going through.”

Bush the poor cousin in Pfizer rollout

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As COVID-19 spread from Sydney to regional NSW in late July, Gladys Berejiklian ordered 40,000 Pfizer doses to be redistributed from the regions to Sydney.

Berejiklian wanted the vaccine for Sydney Year 12 students so they could return to classes for the HSC.

With Pfizer in short supply due to the Morrison government’s bungled procurement process, Berejiklian’s decision did not go down well in the bush.

“There are frontline healthcare workers who [still] haven’t been vaccinated [in regional areas],” Rural Doctors Association of Australia’s CEO Peta Rutherford told ABC News.

Opposition came from the premier’s own side of politics.

Member for Calare and federal minister Andrew Gee called for the Central West to be exempted from the reallocation of Pfizer doses.

“Having just come out of lockdown, it’s not the right time to be diverting the Pfizer doses to the city. We’re only out of lockdown for two days and we’ve got COVID-19 traces in the sewer at Molong,” warned the National Party MP.

Roy Butler of the Shooters, Fishers and Farmers Party, whose state electorate of Barwon stretches from Walgett, Narrabri and Coonabarabran in the east to Broken Hill in the west, also expressed concern.

“There’s a stack of people in Walgett who were booked in to get the vaccination, only for them to have their appointments unexpectedly cancelled,” Butler said.

Less than a fortnight after Berejiklian’s announcement, health officials were rushing to send 1200 doses of Pfizer back to Walgett after the virus hit the town and large swathes of north-western NSW went into lockdown.

Country hospitals lose doctors and senior nurses

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What does it mean for a nurse to be made responsible for a hospital with no doctor?

Wee Waa Community Hospital, 576 km north-west of Sydney, is a 15-bed acute care hospital with a 24-hour ED.

Like many small health facilities in NSW, it has no regular Visiting Medical Officer and has lost its on-call GP. Occasionally, a locum is found to cover weekends.

At all other times, Wee Waa relies on nurses. The ratio is three on morning and afternoon shifts, and two on nights.

Often, however, only two nurses can be found to cover mornings and afternoons because the hospital can’t recruit enough staff – a common problem in small towns.

RN and NSWNMA member Susan Marshall has worked at Wee Waa hospital for 27 years. She says that since it lost its on-call GP, the hospital has found it harder to keep senior nurses and attract agency staff.

“When there are only two nurses on the ward, and they attend an ED presentation, they sometimes have to ask the domestic staff to keep an eye on the high-care patients.

“Two nurses are not enough, for example, to resuscitate a patient and cover the ward as well as make calls to a telehealth doctor.”

Some senior nurses have FLECC (first line emergency care course) qualifications, which allow them to initiate higher levels of assessment and treatment.

However, nurses often feel intimidated and vulnerable due to the absence of a doctor, Susan says.

“It seems the government wants staff to be FLECC-trained to plug the gap left by the doctor, but it’s not entirely safe.

“If you must work outside your scope of practice to get the job done, you can feel insecure.

“Not feeling professionally secure in the workplace can lead to unhappiness with the job – and many senior nurses have left.

“I feel I’m doing a job that’s not always recognised – and I don’t always feel supported by the system.”

Teleheath not enough

Susan does not believe that telehealth can always fill the gap created by the absence of a doctor.

“There will always be cases when you need a doctor on site.

“We are supposed to call the ED doctor in Tamworth, but they often don’t have time for a Wee Waa problem, though they are sympathetic to our predicament.

“I have rung them with triage 1 and 2 patients, and they say, ‘I’m running a resus here and I haven’t got time for you.’ Their workload has increased because we no longer have a doctor.”

Susan says having no medical coverage has led to more patient transfers – sometimes to Narrabri (30 minutes away) but mostly to Tamworth, which can be a six-hour round trip.

“This puts pressure on the ambulance service and leaves our community very exposed without ambulance cover.”

COVID-19 would be the last straw

It also puts more pressure on Wee Waa’s nurses, who are sometimes questioned by ambulance control over whether a transfer is necessary.

“The ambulance coordinator will say, ‘Do you really need to transfer this patient? I don’t have an ambulance to do it and my staff are on overtime.’

“To have to debate this with the ambulance coordinator, who isn’t local, is frustrating and eats up time that we don’t have.”

Wee Waa has so far been free of COVID-19 but if it strikes the hospital, “it could be the straw that broke the camel’s back,” Susan says.

“If someone had to get all PPE’d up to look after a possible COVID-19 presentation in ED, they would not be able to float back to the ward.

“If one or more nurses went into isolation, the department would have to draw staff out of a higher population area or reduce services.

“Compensating within the current roster is just not possible – even with overtime.”

Susan says the hospital has enough PPE, but staff are still waiting for fit testing to be provided.

Rural health boost needed across NSW

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The NSW Nurses and Midwives’ Association (NSWNMA) has backed calls for a public inquiry into the inequities of rural and regional health services and urged the Berejiklian Government to fast-track the allocation of extra nurses and midwives across the state.

Following revelations of adverse patient outcomes on Nine’s 60 Minutes overnight, NSWNMA General Secretary, Brett Holmes, said systemic issues, including poor staffing and skills mix, had to change.

“On behalf of our members, we are certainly open to the NSW Opposition’s proposal for a public inquiry into rural and regional health in NSW,” said Mr Holmes.

“There are plenty of short staffing concerns in these health settings, as well as the myriad of pressures nurses and midwives face as they try to deliver the best acute care in our regional hospitals.

“For years, we’ve been calling for increased nurse-to-patient ratios across all public hospitals in NSW to improve safety and promote better patient outcomes, but the government continues to refuse to commit to mandatory minimum staffing.

“For too long, the government has ignored the evidence that nurse-to-patient ratios do save lives.

“The government must also prioritise the roll-out of additional nurses and midwives it promised, instead of waiting until weeks out from the next state election in 2023.

“Access to adequate healthcare services is a basic right and should not be compromised year after year to save budget bottom lines.

“Our regional communities have faced ongoing battles with drought, severe water shortages, catastrophic bushfires and now further economic downturn thanks to COVID-19. They deserve access to the best health care possible, regardless of where they choose to live.

“The government has also neglected to adequately increase the number of Clinical Nurse Educators available to better mentor junior nursing staff throughout regional areas.

“The government must stop relying on the goodwill of nurses and midwives to carry our underfunded and understaffed public health system through, while maintaining a commitment to their own professional obligations. Enough is enough.

“The government must stop abrogating from its duty of care to patients in our public hospitals and support the health staff trying to deliver safe and adequate care.”