Abstract: Despite the widespread acceptance of the value of supervision among practitioners and the large quantity of literature on the topic, there is very little empirical evidence in relation to its effect on clinical practice. It is not clear whether supervision actually produces a change in clinician behaviour, or whether it produces benefits in terms of client outcomes. This thesis evaluates the impact of clinical supervision on five co-ordinators in a rural home care setting. It looks at the impact clinical supervision has on their practice and professional growth. The nurses all belong to one organisation, Access Homehealth Ltd. The study builds on the findings of a clinical supervision pilot, which was trialed within the organisation in 2002. The pilot examined which model of supervision was most beneficial for Access Homehealth staff. Clinical Supervision is defined as a designated interaction between two or more practitioners within a supportive environment, that enhances reflective practice and professionalism, which in turn contributes to improved practice and client outcomes. The methodology of this research was qualitative evaluation. The themes which emerged related to personal support, managing stress and alleviating feelings of isolation, reflection, enhancing practice, improved communication skills and the concept of clinical supervision as a safety net. Participants also revealed that one-on-one supervision appeared more helpful than group supervision, and that phone supervision facilitated in-depth dialogue. These findings are important, as they demonstrate it is feasible to simultaneously offer a number of formats of clinical supervision within one organisation, allowing for the organisation to provide what works best for different workers. They also show that clinical supervision is a valuable and useful support tool for home care co-ordinators in order to facilitate empowerment, reflection and growth in practice. Further research is needed to provide evidence of the benefits of supervision on improving client outcomes.

Abstract: In this chapter the author uses storytelling to explore the legal and ethical issues she experiences as a rural volunteer registered nurse. She describes the relationship between the nurse and community embodied in areas such as the public perception of nurses, and discusses aspects of her practice in the light of the particular legal and ethical context of rural areas.

Abstract: This chapter describes the development of a nurse-led after-hours telephone triage service in a rural secondary hospital in the Hawke's Bay District Health Board area. This service was a response to the health restructuring in the 1990s, which had led to the shift of secondary services out of the rural areas, and workforce recruitment issues. Secondly, it discusses the process and findings of a research project undertaken to identify and describe telephone callers' reported outcomes after using the service. The study found a high level of satisfaction amongst callers and a high level of compliance to advice.

Abstract: A qualitative framework was used to explore the nature and the quality of interactions between sole on-call primary health care rural nurses and secondary care doctors. This study is framed as investigating a specific component of rural nursing practice and as being representative of the primary-secondary care interface. The primary-secondary care interface is crucial for the delivery of patient-centered care, and there is an increased focus on preventive primary health care. The New Zealand government sees the repositioning of professional roles and increasing emphasis on collaboration as an opportunity to re-define and address the current constraints to nursing practice. This has resulted in tensions between the medical and nursing professions. These tensions are not new, with the relationship sometimes marred by conflict which has been attributed to historical medical dominance and nursing deference. This study explores some specific areas which affect collaboration and makes recommendations at the national, regional and individual level to address them.

Abstract: The author takes a multidisciplinary approach to examine how the location and concept rural is defined and provides a critique of the disparate definitions available. Definitions encompass different disciplines such as sociology and anthropology, and there are national distinctions based on historical factors. The chapter also investigates the way researchers speak about rural people, particularly as the human aspect of health is a primary concern to nursing. The focus is on the socio-cultural, occupational, ecological, and health aspects of rurality. The Rural Framework Wheel is introduced, which is a method to categorise rural contextual definitions. Rurality is presented as a variable and evolving concept that provides particular challenges to nursing practice.

Abstract: A qualitative framework was used to explore the nature and the quality of interactions between sole on-call primary health care rural nurses and secondary care doctors as a component of rural nursing practice and representative of the primary-secondary care interface. Crucial to patient centred care, the premise was that the quality of this interface would be variable due to multiple influences such as: the historical nurse/doctor relationship that has perpetuated medical dominance and nursing subordination; current policy direction encouraging greater inter-professional collaboration; and changing role boundaries threatening traditional professional positioning. A total of 11 nurses representing 10 separate rural areas participated in semi-structured interviews. Rural nurses typically interact with secondary care doctors for acute clinical presentations with two tiers of interaction identified. The first tier was presented as a default to secondary care doctors for assistance with managing primary care level clinical presentations in the absence of access to a general practitioner or an appropriate Standing Order enabling appropriate management. The second tier presented itself as situations where, in the professional judgement of the nurse, the client status indicated a need for secondary level expertise and/or referral to secondary care. The needs of the rural nurse in these interactions were identified as access to expertise in diagnosis, therapy and management, authorisation to act when intervention would exceed the nurse's scope of practice; the need to refer clients to secondary care; and the need for reassurance, encompassing emotional and professional issues. The quality of the interactions was found to be variable but predominantly positive. Professional outcomes of positive interactions included professional acknowledgement, support and continuing professional development. For the patient, the outcomes included appropriate, timely, safe intervention and patient centred care. The infrequent but less than ideal interactions between the participants and secondary care doctors led to professional outcomes of intraprofessional discord, a sense of invisibility for the nurse, increased professional risk and professional dissatisfaction; and for the client an increased potential for deleterious outcome and suffering. Instead of the proposition of variability arising from interprofessional discord and the current policy direction, the data suggested that variability arose from three interlinking factors; appropriate or inappropriate utilisation of secondary care doctors; familiarity among individuals with professional roles and issues of rurality; and acceptance by the primary care doctor of the sole on-call primary health care rural nurse role and the responsibility to assist with the provision of primary health care. Recommendations for improving interactions at the interface include national, regional and individual professional actions.

Abstract: Recent changes to the way that health services are provided and issues related to the rural health workforce are creating an international crisis in the availability of rural maternity care. International trends show a workforce decline in rural general practitioner obstetric specialists and rural midwives, as well as a decline in rural births. The aim of this study is to highlight the maternity needs of rural New Zealand women. Further, it discusses how the changes to maternity services in New Zealand, over the last sixteen years, have impacted on the rural nurse and midwife role and therefore on service provision. This information is intended to identify issues that could be used as the basis for development of a uniquely rural model of maternity care.