Translating aspects of The National Rural and Remote Nursing Generalist Framework 2023–2027 into practice: opportunities and considerations

Reforms that grow the capabilities of the health workforce are critical to improving outcomes for populations residing in rural and remote areas of Australia.¹ As the backbone of the rural and remote health workforce,² nurses are central to improving access to health care for populations residing in rural and remote areas who otherwise experience inequity and poorer health outcomes, relative to metropolitan areas.^3,4 The Australian Government’s recent release of The National Rural and Remote Nursing Generalist Framework 2023–2027 (referred to as the framework)⁵ offers a fresh approach in identifying opportunities to strengthen the rural and remote nursing workforce.

Developed by an expert steering group of representatives from nursing peak bodies, the framework includes four domains: (1) culturally safe practice; (2) critical analysis, relationships; (3) partnerships and collaboration; and (4) capability for practice. The framework also includes capabilities within these domains for Registered Nurses (RNs) practicing in rural and remote settings.⁵ Rural and remote settings are defined using the Australian Government’s Modified Monash Model (MMM) as categories three to seven (MM3 – large rural towns; MM4 – medium rural towns; MM5 – small rural towns; MM6 – remote communities; and MM7 – very remote communities). It is in these areas where over 19% of the Australian population resides, and often in lower socio-economic circumstances than those in MM1-metropolitan areas.^6,7 A clear definition of rural and remote settings is a strength of the framework⁸ and aligns with other Australian Government health workforce policy (e.g. Rural Health Multidisciplinary Training (RHMT) program), which have transitioned to using the MMM to define rurality.^9,10 Further, defining rurality using a geographical classification system ensures that the framework accommodates changing levels of access and population needs given the MMM will be updated with the March 2023 release of the Australian Bureau of Statistics’ Australian Statistical Geography Standard Remoteness Areas based on the 2021 census.¹¹ This is important as areas are reclassified on a five yearly basis following the national census (e.g. Mount Gambier in South Australia reclassified from Inner Regional Australia to Outer Regional Australia¹¹).

A framework for RNs working in rural and remote settings that is of national scale is novel. Similar work was undertaken in Canada where a framework for rural and remote nursing practice was developed through a review of the literature and engagement of an advisory group.¹² Like the Canadian framework, further exploration of how the framework can be translated into practice given the diversity of rural and remote communities, variations in the scope of practice, and the regulatory environment across jurisdictions (i.e. states and territories), is required.^12,13 These issues are well established for the nursing workforce in Australia,^13,14 and even more pronounced in rural and remote settings.^15,16 For example, for nurses practicing in remote and isolated areas of Australia, research identified the need for greater national agreement as to what preparation for practice is required – an area that the framework seeks to address.¹⁵

Capabilities included within the domains of the framework expand on the Nursing and Midwifery Board Australia’s (NMBA) Registered Nurse Standards for Practice (2016).¹⁷ However, many of the capabilities included require additional support for RNs, particularly those seeking to develop capabilities at the level of proficiency. Further, many rural health care services are under pressure and may not be well positioned or resourced to provide this additional support to their nursing workforce – an issue exacerbated by the coronavirus disease 2019 (COVID-19) pandemic.¹⁸ For example, capability 2.2 Evidence-Based Ethical practice (Domain 2. Critical Analysis) of the framework states:

Utilises relevant data to identify best practice, place- and strengths- based person-centred interventions, co-designed with people, families, communities and the multidisciplinary team in the rural and remote context…

The skills required for a generalist RN working in a rural or remote setting to address capability 2.2 exceed the NMBA’s Registered Nurse Standards for Practice (2016) (e.g. standard 1: thinks critically and analyses nursing practice).¹⁷ Using and analysing data, applying research methodologies and methods (e.g. co-design), and implementing interventions developed through this process, is a specific skillset that would be unlikely to be commonplace for RNs not only working in rural and remote settings, but also in metropolitan settings. A qualitative study undertaken across metropolitan, rural, and remote settings identified that RNs encounter challenges when engaging with research (i.e. language, numbers, and statistics).¹⁹ To address this, research education is a key strategy to building the research capacity of nurses in health care settings,²⁰ coupled with supporting pathways to higher education (e.g. Doctor of Philosophy). Although it is necessary to invest in building the capacity and capabilities of the nursing workforce to engage with research as part of the shift towards place-based research,²¹ it is important to balance this with the need to not burden an already strained workforce.

The question remains how capabilities stipulated within the framework for generalist RNs can be supported from a workforce perspective. The Australian Government’s RHMT program is well positioned to continue supporting the rural and remote nursing workforce to build these capabilities through a growing network of 19 University Departments of Rural Health (UDRH) located in rural and remote settings across Australia.²² An evaluation of the RHMT program identified the contribution of the program to addressing rural nursing workforce shortages by supporting nursing student placements, and supporting training and research in rural and remote settings.²³ This includes supporting nurses to lead research focusing broadly on rural health issues, rural training strategies, rural health workforce development, Aboriginal and Torres Strait Islander health and wellbeing, and innovative models of care (aligning with parameter five of the RHMT program).²⁴ From a policy perspective, there is an overlap between the RHMT program and the capabilities of the framework (e.g. Aboriginal and Torres Strait Islander health), creating an opportunity for rich collaborations across the UDRH network for translation.

The framework is timely in advocating for nursing workforce reforms in rural and remote areas. Further consideration of how the nursing workforce can be supported to translate the framework into practice is required. Identifying strategies to support RNs in developing research capabilities is imperative, and likely achievable through the continued support of the RHMT program, which includes research and training support. Leveraging from this national network that is geographically expansive and has a long-term strategic impetus for growing the rural and remote nursing workforce provides an opportunity for translating aspects of the framework at a national scale.

Data availability

Data sharing is not applicable as no new data were generated or analysed during this study.

Conflicts of interest

The authors were not members of the steering group who developed The National Rural and Remote Nursing Generalist Framework 2023–2027. HB, SC, and VLV are researchers funded under the Australian Government’s Rural Health Multidisciplinary Training (RHMT) program.

Declaration of funding

No funding was received for the preparation of this article.