The Rural Way: Rural Nurses’ Contribution to New Models of Health Care, Reducing Health Disparities – Stories from Practice

Abstract

This chapter reports on a research project that set out to capture the unique stories from rural nurses from Aotearoa, New Zealand. During the past three decades changing socio-political and economic contexts have affected the delivery of health care while rural nurses have responded with new models of practice which has resulted in an emerging rural nurse discourse related and specific to rural New Zealand. Rural nurses have maintained and, in some cases, improved the health care of these rural communities. A total of 26 rural nurse participants shared their stories providing data to explore the structured phenomenon of rural nursing in New Zealand. Personal and human dimensions are illuminated, as the in-depth meaning of the experience is described by each individual storyteller. Interviews were conducted to collect retrospective stories uncovering the participants’ rural nurse journey. Revealed are a sense of place and people, involving what nurses’ express, as the rural way. A nursing discourse is developed which complements and extends international theories. The rural nurse of New Zealand is imbued with pioneering spirit; entrepreneurial practice shaped by their rural communities highlighting what we suggest is the rural way. Further expansion of the rural way was uncovered with follow up interviews exploring their practice during the COVID-19 pandemic.

1. Introduction

The professional identity of the rural nurse from Aotearoa New Zealand came of age between the 1990s and the early 2000s. This time period is associated with significant changes to the governance, funding and delivery of health care in rural contexts as a result of the global financial crisis of the late 1980s. Changing health care ideologies moved away from a top-down approach to a bottom-up approach reflected in the major health care reforms revealing the adoption of neo-liberal ideology [1]. The National government of the day acknowledged continuing inequalities in health, for Māori (indigenous population of Aotearoa New Zealand) and Pacific populations was continuing to decline with extensive statistical differences between Māori and non-Māori and equally between urban and rural regions [2]. Changes where needed to address these disparities [2]. The government’s aim was to increase efficiency and address these needs while providing healthcare in the most economically and practical ways [3]. The government authorised major health reforms, resulting in changes for the provision of healthcare [1] delivery, funding, governance structures [2, 3] and models of healthcare [4, 5, 6, 7].

The establishment of Rural Community Trusts (RCTs) was one outcome of the country’s major health-care reforms [8]. RCTs designed and managed their own individual local health services, this model was regarded by the government as innovative and came with associated cost savings. As well as encouraging community involvement in health-care decision-making [8] the RCTs assisted in the development of “by Māori for Māori” iwi providers [9]. The benefits of RCTs became the funding structure that improved and supported community participation, collaboration, and teamwork. Further this ideology was extended and underpinned in the early 2000s by the ‘Primary Health Care Strategy’ [10] and further laid the foundation in which to position nurses at the foreground of the delivery of Primary Health Care (PHC) and improve nurses’ contribution to the delivery of health care. This shift in focus has been beneficial for the advancement of PHC nurses and in particular rural nurses’ practice development and contribution to the delivery of sustainable health care.

This original qualitative research aimed to explore rural nurse practice in Aotearoa New Zealand following decades of change leading to the development of new rural health delivery models. The rural nurse participants shared their stories exploring the past, the present and the future experiences leading to a unique rural nursing discourse which complements and extends the international literature from America [11] Canada [12] and Australia [13] in alignment with health beliefs of rural populations and the nuances associated with geographical locations. Traditional discourses aligned with rural nursing practice include personal and professional connections with the rural community; being known in the community; dual relationships; and always being on call; broad scope of practice; jack of all trades, master of none; and a sense of belonging to the geographical location. These discourses are well entrenched within national and international nursing organisations; rural communities; policy development; education, workforce planning and research informing practice.

The occupational title of the ‘rural nurse’ from Aotearoa New Zealand has been questioned by Ross [14] as to whether this title is an adequate portrayal of their practice and contribution to the delivery of health care? In short, her findings suggest this title does not do justice to their practice and further research into this goal is required. This research seeks to investigate further rural nurses’ practice and contribution to health care revealing that rural nurses throughout the latter part of the twentieth century and early part of the twenty-first century were pivotal in pioneering new models of practice; expanding the scope of nursing services available to their rural communities; reducing inequities while maintaining and in some cases improving health. More recently COVID-19 has created new challenges for those rural nurses and rural communities [15]. Follow up interviews in 2020 heightened further demands on rural nurses’ practice, further revealing pioneering practice adding to the unique rural nursing discourse.

2. Narrative research: diving into the story

A narrative inquiry approach was the methodology chosen for this research, providing “… a way of understanding and inquiring into experience” [16]. This qualitative research celebrates the power that story has, to explore meaning, make connections, entertain, and build empathy and share experience with others [16, 17]. Haven [18] recognises the power the story has to explore meaning and make connections between the storyteller and the recipients. Stories have provided the data to explore the structured phenomenon of rural nursing in New Zealand—as lived and told by experienced rural nurses.

2.1 Rural nurse participants

Rural Nurses from Aotearoa New Zealand were invited to share their stories. The snowball effect was engaged with revealing a total of 58 expressions of interest, of which 40 rural nurses met the research criteria (rural practice in New Zealand for more than 15 years) and 26 rural nurses were able to commit to the project requirements and timeframes. These rural nurses’ ages ranged from 40 to 70 years while their demography included nurses of Māori (indigenous population of Aotearoa New Zealand) and European descent, male and female, recently retired and currently employment, representatives from all regions of habited Islands from the far North of the North Island to the far South of the South Island. Island groups (North and South Islands, Great Barrier, Chatham, Pitt and Stewart Island) refer to the Aotearoa New Zealand map in Figure 1. Participants for this part of the research project were not identified.

Figure 1.

Map of Aotearoa, New Zealand. Source: Created and published with permission from Chris Garden.

2.2 Data collection

The original research was conducted in 2017/2018 we engaged with semi-structured interviews to collect retrospective stories covering the participants rural nurse stories either face-to-face, SKYPE (video) or telephone. Interviews ranged from 45 to 90 min in length. Interviews were, framed around Clandinin and Connelly’s [19] three-dimensional space narrative structure which is a model that examines personal and social interactions across the continuity of time and context, as well as personal and social features experienced by both the researcher, and participant. The framework was shared with all participants before the agreed interviews, however during the interviews began with an open question from the interviewer—“Tell me about your rural nurse journey”. Each nurse was a primary source, sharing their unique nursing story. Each interview was recorded, transcribed, and sent back to the interviewee (rural nurse) to check validity, or to add key forgotten moments. Each transcript was then returned to the researchers. Each nurse was a primary source, sharing their unique nursing story.

There were 16 rural nurses from the original research project) who agreed to have their stories published in Stories of nursing in rural Aotearoa: A landscape of care [20]. These rural nurses in 2020 were contacted by email inviting them to contribute with follow up interviews exploring their practice during the COVID-19 pandemic. Nine of the 16 rural nurses agreed to participate and were interviewed by the first author. This follow up interview enquired whether the COVID-19 pandemic had affected the rural nurses’ practice and if so, seek what were the outcome?

The interviews were digitally recorded via zoom meetings, edited to remove identifying features of individuals mentioned and then developed into podcasts and broadcasted on Otago Access Radio (https://oar.org.nz/) before been thematically analysed. Podcasts consist of positive conversations with people from around the world related to COVID-19 is a further expansion of the rural way related to rural nurses from Aotearoa New Zealand uncovered

2.3 Data analysis

Each transcript was read at least twice by the researchers with key repeated concepts identified by commonality across interviews: the umbrella concepts of past, present and future, situation and place. Data from each interview was then coded into themes and subthemes until saturation occurred and no new themes emerged [21]. Researchers could not guarantee absolute confidentiality to participants, as pioneering innovation can be traced back to place and sometimes person. Participants knew personal and community names would be protected, but that emergent themes and specific detail might identify location. We placed safeguards to protect participants by asking all participants to check transcripts, with highlighted areas we thought potentially might be recognisable. Once corrected transcripts were returned, we coded each transcript, removing the participants name, individual participants were identified by code only (by number). A phenomenon of interconnected narratives emerged, showed how stories of the past shape the present and influence discourse All transcripts are kept on a passworded hard drive and will be kept for seven years as per ethical requirements.

Ethical approval was obtained from Otago Polytechnic Research Ethics Committee, Otago Polytechnic, Dunedin, New Zealand in 2017 and extended in 2020 to accommodate further interviews from the original rural nurse participants who consented to have their stories published in a book. Ethical approval also included consultation and engagement from the Office of Kaitohutohu. The Kaitohutohu office at Otago Polytechnic upholds the mana (integrity) of the partnership with the local Māori (indigenous population Aotearoa New Zealand) community, and is consulted during research development, looking at the proposed research from a Māori Kaupapa point of view. Māori are under-represented in the nursing profession, comprising only 8% of practising nurses [22] so the inclusion of Māori as part of this research is of the utmost importance to further our understanding and future engagement [23].

We were aware the research was likely to involve Māori as there is a higher number of registered nurses identifying as Māori in the rural practice setting (N = 59; 11.6%) of 6.5% of the overall workforce [24]. Statistics show that 14% of the New Zealand population identify as Māori, with over three quarters of this population living outside the Auckland region, making up a significant part of the rural communities [25] “Rural nursing is also clearly a valued setting for Māori registered nurses’ employment…” themes from the rural nurses’ stories could “… include reference to tikanga Māori (a Māori concept valuing Māori knowledge into practice), within the context of describing their work” [23] p. 68.

3. Findings and discussion

Engaging with a thematic analysis has revealed a unique discourse of rural nursing in Aotearoa New Zealand. Rural nurses revealed their innovative practice exposing their contemporary identity of the nurse practising in the rural context. This rural nurse discourse identifies the rural nurse as a pioneer supplying the backbone of health care to the community; an entrepreneurial practitioner expanding the limits of scope of practice to meet community needs. The creative development of tenacious nurses and local communities’ embracing responsive solutions and new models of healthcare to accommodate the challenging landscapes and changing socio-political tides, accommodating indigenous provision of health care highlight what we suggest is the rural way, as supported by the following data and discussion.

3.1 The rural way

A description of the rural way incorporates values, attitudes or characteristics that are common in rural indigenous and non-indigenous rural people [23]. These features of rural people or communities were often seen as being different to urban environments, a product of geographic context and isolation from others, encompassing a way of being and a Māori way of being in the rural. Being in the rural revolves around embracing the rural, rural culture, values, beliefs and performing in the rural. For example, resourcefulness (mention is made to #8 fencing wire (Figure 2) a well-known depiction of New Zealanders ability to mend, fix or create solutions to problems by using #8 wire) is made necessary due to being at a distance from many health resources as discussed by the following participants:

Figure 2.

Dealing to the damage with Number 8 wire. Source: Martin London Photography (published with permission).

People are very different in a rural area, I think, than they are in the city. They are very different people; in that they are more community orientated. I think in the city, a lot of people don’t even know their neighbours. And in rural areas, they are ‘#8 wire’ people; they manage to fix things that you think ‘wow, look at you, look what you managed to do!’. They’re quite resourceful. (Storyteller 12)

They’ve [rural people] got a ‘can do’ attitude. They care about their neighbours. They’re “greenies” in their own right, so they love the environment they live in, and they look after it (believe it or not). They’re known for their number 8 wire approach and their ability to diversify when the need arises. (Storyteller 11)

It’s about 2 ½ hours. Ambulance, it can be up to 3. And if you’ve got – obviously - road works, or flooding, we’re actually chopped off. We can’t get there, and it’s only by helicopter. But then, if the weather’s no good, the helicopter can’t fly anyway. So, we do need to have some sort of independence, and be able to intubate and keep somebody alive until help can come. (Storyteller 16)

Many (but not all) of the rural nurse participants had been born and bought up in rural communities. The specific rural settings the nurses lived and worked in were often spoken about as part of their own connection with the rural, leading to a sense of place and a sense of belonging (rural knowing) (Figure 3). Knowing is associated with understanding the rural context, community and the local unique rural community rhythm, which connects the rural nurse to identify with that rural community as revealed by the following storytellers:

Figure 3.

The hay barn is full on a fine day in Paradise. Source: Martin London Photography (published with permission).

I live it, dream it. That’s massive for me. Space – so, a paddock with some sheep and a hill and a tree and a mountain in the background, for me, is prayer. Literally. Because I love – I love – the rural setting. I love the fact that you’re this tiny little town surrounded by this magnificent beauty. (Storyteller 10)

I think this is paradise myself, that’s why I wanted to come back, I love the hills, I love the seasons yeah, it’s perfect being here I will always stay here. (Storyteller 9)

Living in the rural area, I understand the nature of their farming lifestyle, both dairy and mixed farming, logging, freezing works, the seasonal work like shearing, lambing, tailing, haymaking cropping and all that entails, you know the dangers of tractors quad bikes. I supported the local rugby teams often knowing the players. The families that have been here for a long time, I know them well. (Storyteller 1)

Despite a love of rural environments, almost all interviewees discussed challenges that they pose. The most cited challenge was isolation due to long distances from other healthcare centres, and weather (and typically a combination of the two). Geographic factors affect healthcare delivery in rural settings but are also cited as a reason why rural nurses require a resilience – they need to be able to provide care and the necessities of life in areas with limited resources, we consider these nurses both pioneers and entrepreneurial practitioners.

3.2 Pioneering practice

Where health services did not exist, nurses employed a pioneering spirit to develop a service that met the client and community needs. They forged new roles, did further training, fundraised for resources, and met challenges with courageous strategies. Changing governance structures meant that nurses were able to shape the direction and delivery of healthcare during the major health care reforms. Rural nurses initiated many practices, whose origins have now been absorbed into contemporary health practice. Like all new practices, changes were scaffolded to make innovation possible. In this case, nurses becoming intravenous-certificated was an important first step to providing local access to chemotherapy. The alternative model required residents to travel 3–5 h, in each direction, to an urban health-care facility (ese rural nurses set out to avoid residents having to travel long distances to acquire treatment in urban contexts) as they progressed with new and never been offered health care services firstly by nurses and secondly in rural regions in the 1990s. This innovative practice was later recognised by the establishment of Nurse Specialists. These approaches to the delivery of healthcare were designed to meet the localised health needs of the community as depicted in the following excerpts:

[w]e needed to adapt, which as rural nurses we do very well. So we changed it [the delivery of chemotherapy] to more of a medical day unit and took on doing other transfusions…(Storyteller 16)

So, I pioneered additional services that the nurses could provide for the community, for example cervical smears, which at that time was not the norm for nurses to be offering. (Storyteller 1)

The rural nurses acknowledge the community role and are encouraged to pioneer and deliver health services in local regions that accommodates the particular nuances related to that community for example, Māori nurses embrace their own identity and have a responsibility to meet the needs of their families or whanau which involves caring for the whole family and not just the individual patient because whanau play a role in a patient’s recovery [26].

[In establishing operating mobile ear health clinics in rural isolated regions with a high Māori population] We were taking away all the barriers to access, for example, unwarranted cars, unregistered cars, unregistered drivers, petrol in the tank. We were just trying to drop all those barriers so the children could get what they needed without adults putting up the problems that they had, that were getting in the way. (Storyteller 2)

Rural nurses share on-call (after hours provision of emergency and acute health care) with general practitioners covering 24 h of healthcare at the weekends and during weeknights. One noticeable difference between rural and urban nursing practice has been the expectation that rural nurses would provide an emergency health-care service in the form of Primary Response in Medical Emergencies (PRIME). It is important to acknowledge this in the context of changing models of healthcare and funding and the provision of sustainable healthcare by rural nurses. PRIME is distinct to Aotearoa New Zealand operating only in rural locations and funded by the Ministry of Health and the Accident Compensation Corporation (ACC) and is administered by St. John Ambulance service. PRIME utilises the skills of speciality trained rural GPs and/or rural nurses in areas to support the ambulance service where the response time for assistance would otherwise be significant or where additional medical skills would assist with the patients’ condition [27].

… we got a defibrillator and introduced a higher level of care, making the practice more of a casualty outpost rather than just a house with a medical kit in it. (Storyteller 3)

[Before PRIME¹] I found myself stitching people up and putting IVs in without any training… We trained sideways, literally doing our nursing training, our extra training, I trained to Level 4 as an ambulance officer. (Storyteller 3)

…in the local hospital… there were no permanent medical doctors in the hospital and the nurses ran the hospital with the General Practitioners’ support… I was a ‘jack of all trades’ and would do a bit of this and that.

The RCTs, including nursing services, were driven by the health needs of their communities which, over time, granted rural nurses a strong community involvement while enhancing communities’ social capital (as discussed in the excerpts from the rural nurses’ stories above). Nurses talked of adapting their practice to accommodate community need to achieve this they needed to be responsive to the community be tentative and pioneer new approaches and models of practice. In the long run, all these trusts ensured the feasibility of community health services, having been redesigned to perform this function [8]. The trusts generally employed all local health-care staff including the general practitioner and rural nurses. These new employment arrangements gave the RCTs significant advantage the local health professionals were in a strong position to work collaboratively, maintaining effective teamwork and sharing skill base as a result, which benefitted the community.

Many of these aspects of rural nursing show a pioneering spirit, several of these historical practices are now incorporated into community nursing as routine everyday practice. Rural nurses have very autonomous roles, with high levels of responsibility. This both expands nursing skills to the edge of scope of practice, but also sometimes restricts what intervention is possible. Nurses often spoke of “being it”, “the only”, very different from team nursing in an urban hospital setting as highlighted by the following rural nurses:

It really came home to me one night that I was it. … In the rural setting, I guess, those of us who do work here realise we often have to step up to the challenge… It is a different culture, an unspoken knowing that you will work together to do the best, whatever it takes. (Storyteller 9)

We’ve had to be quite resourceful in what we do and how we work. We rely on a lot of nurses stepping up into different specialties [like Rural Nurse Specialist, Nurse Practitioners, Clinical Nurse Specialists] because it’s very difficult to retain doctors in a lot of those areas… It’s an exciting place for a nurse to work. You get to work truly to the top of your scope of practice. (Storyteller 11)

…rural nurses [need to be] recognised for the skill set that they have, because I believe it is different, it’s so different. But that we can support them so that they can do it knowing that they’re going to be backed up, knowing that they’re not going to fall into working outside of scope. All those things that are very, very difficult when you are on an Island on your own… (Storyteller 10)

Islands provide their own special geographic constraints. Islands are considered as distinct places. Islands are different from the mainland areas especially when they are situated the furthest away from adjacent mainland communities [28]. Islands are surrounded by water; connected/disconnected; isolated; habituated; uninhabited, while having similarities with others or differences and experience their own challenges [29]. Challenges may pertain to the island’s own climate which have a direct bearing on island and rural culture and economy. This brings demands on the services and supply industries and can also impact on resources as dis-economy of scale is experienced living on an island because of small community populations that raises costs of living including transport, production of electricity and the moving of goods onto the island all come with a cost (Figure 4) [30]. And further consideration of rural peoples’ resilience, independence and self-sufficiency relates to rural Island life as highlighted in the following excerpts:

Figure 4.

Terminal building and taxi at Pitt Island airstrip. Source: Martin London Photography (published with permission).

Internationally they say that there is something different – or set apart about people who choose to live remotely… There is a need for the people to be self-sufficient, independent and resilient to enjoy or, in fact, survive island life. (Storyteller 6)

Islands are bound by geographical constraints - distance and boundaries. An island is defined as a piece of land surrounded by water – often also by isolation – by detachment or surrounded in some way…. A good example being in poor weather you just can’t get a seriously sick patient off the Island as the helicopter cannot land whereas on the mainland there may be other options. (Storyteller 6)

…when I realised my father was having a heart attack that night, it was 10 o’clock at night, and the first thing I did was – rather than think ‘well, is he going to survive’ – I looked out the window to see what the weather was like. You couldn’t have a plane because it was dark, so were we going to be able to get a boat to get him off the Island? (Storyteller 10)

We’re very vulnerable to commercial decisions here because we rely on businesses that have ferries and planes, and if they change their practices, that can change things overnight for what we do here. (Storyteller 3)

We further identified several themes that rural nurses’ practice typically possesses for example innovation and adaptability while working autonomously but in collaboration with the residents and team members aligned with the rural community which we have identified as the rural nurse as entrepreneurial practitioners.

3.3 Entrepreneurial practitioners

Rural healthcare professionals are usually in reciprocal relationships with the community they serve. They see the community itself as inherent to their practice, and for some nurses, to their sense of self and for Māori nurses this sense of self relates strongly with knowing their communities and whanua contributes to a sense of belonging, provides insight, and helps to establish therapeutic relationships [23]. Many of the rural nurses expressed that they were highly supported and valued by their community. This support is not only due to good will and established relationships, although that is undoubtedly a part of it. Due to matters of geographic isolation and resource scarcity, community support is often a requirement if the community is to have operating healthcare services:

I feel supported by the community as I nurse. The proof of that is when there’s an emergency. It is common that the locals will stop and assist. Someone might offer to carry my heavy packs into the bush, others will rush off to find family members of the injured. And afterwards some may phone me up saying, ‘oh, I realise that you were up really late last night, can I blah blah blah for you?’ (Storyteller 6)

Sense of place is important to both the nurse, and to the patient. Relationships and empowering clients to make their own choices about location are seen as important to the rural nursing role, while recognising the increased risks isolation entails. An often-discussed aspect of rural nursing was enabling people to maintain their independence; to remain in their home or the local community whilst receiving care:

And I think a lot of times, when people talk about encouraging people in palliative care to die or saying that people want to die at home, I think ‘community’ is what they mean. ‘Home’ doesn’t necessarily always mean the house where they lived. But it means where they’re comfortable, where their community is, where their support is… (Storyteller 7)

So, yes, I think we provide a magnificent service, I really do. An essential service. We keep people out of hospital or bring them home much earlier. (Storyteller 12)

Rural nurses show ingenuity in the face of scarce resources, often working in isolation with high responsibility and autonomy. Despite the increased likelihood of working by oneself in a rural context, the interviewees recognise that working with other healthcare professionals is vital to ensuring the best outcomes for patients, but often collegial relationships are at distance:

I work in partnership and collaboration with the General Practitioners, I support them, just as they support me. They trust my ability allowing me to manage their patients. There is real teamwork here. (Storyteller 1)

Although pre-established connections cause challenges with maintaining professional boundaries it can be of benefit to patients in that these relationships can be useful in a therapeutic sense, but also in that health care practitioners feel accountable to the community:

… sometimes when you know them [a patient who cannot be saved], you’re dealing with your own grief. It’s nothing like the grief of the family, obviously, but you’re still dealing with your own grief. And then you think – it’s the old beat up story – ‘did I manage to…’, ‘was there anything else I could have done’, or ‘did I not do…’. And as I said, you’ve got nobody to bounce those ideas off because you’re there on your own. … You’re there, until somebody else turns up. (Storyteller 8)

Understanding the community, and its needs are necessary to be able to forge creative ways to provide services that are accessible and appropriate. Nurses often have a pre-established connection with patients or can quickly form one, sometimes patients are family or friends, working in partnership over long periods of time has numerous advantages for the provision of patient-centred health care linking health requirements and needs and building a sense of connectedness and fulfilment for the nurse. These links create additional complexities, but also opportunities for additional support. Working in partnership with the patient/client is seen as vital, requiring a connectedness to the community. In rural nursing, nurses often get to see the difference they make through continuity of care. Rural nurses describe great satisfaction from seeing their skills being valued by their clients and are professionally invested in the change they help engender with clients:

…you tell them to go to so-and-so because they will be able to fix it for you, whether that’s home help or something. I’m very aware what’s available in the community (Storyteller 13)

If I nurse somebody who comes from [community name removed] …, you know there’s issues around distance, you know there is an issue around the limit of health services in their home area, what their shopping and other services are like. You actually really do understand some of the challenges for people, and that makes a big difference. (Storyteller 5)

… you watch people grow. Especially young mums with babies that are struggling… And then you watch them flourish and they get it all together. And you watch the children flourish and go to school, and then you see them in school. It’s kind of nice. (Storyteller 8)

3.4 Entrepreneurial practice the nurse practitioner

The rural nurses we interviewed revealed the practice models they adopted in response to funding changes. Firstly, nurses had the opportunity to purchase and govern general practices, which were traditionally owned and operated solely by GPs – those with a medical background. Nurse Practitioner training was seen by nearly all respondents as the extra training that legitimised what nurses had to do anyway in rural settings, but previously through indirect routes. However – it was generally felt that their work was not understood, appreciated, or valued by those outside of the rural setting:

By doing my Nurse Practitioner training, I could then offer this broader, rounder service. I could finish the consult by signing the script, ordering more medication, or – more importantly than the medication – ordering an x-ray, working out which bloods were needed and why. So, investigations were bigger for me in becoming a Nurse Practitioner than prescribing was. Prescribing was the added plus.

(Storyteller 10)

Nurse Practitioner was that I felt that it was really helpful to have the ability not just to prescribe, but to actually be able to assess properly; to learn how to assess, diagnose, treat, look for problems and do as much as I can in the areas preventing people from having to come up to tertiary care. (Storyteller 7)

3.5 Entrepreneurial practice responsive to change

A common sentiment among rural nurses was that industry and demographics within rural communities have changed dramatically over time (Figure 5). Changes in industry are said to explain the changes in demographics, with more transient workers and immigrant workers unfamiliar with the Aotearoa New Zealand health system and language barriers. This changes the context in which rural nurses operate, as the high degree of interconnectedness in rural communities, while still existing, is somewhat diminished:

Figure 5.

Chatham Island industries: Hotel, fish factory and sheep penned for embarkation. Source: Martin London Photography (published with permission).

But in the rural areas, there are now more transient populations. The dairy farm workers in the [place name removed] area alone are from 10 different nationalities. Many don’t speak English. So you have a language barrier, communication barrier, expectations [that do not align with how the New Zealand health system works]. (Storyteller 1)

After starting this job for a couple of years, I could have driven right through my area and named every house, every child, every person. I don’t even bother trying these days. (Storyteller 8)

It was very obvious when working in Public Health especially in the school situations as the migrant workers [from diary conversions] brought with them their own social issues previously not seen in the established communities. (Storyteller 14)

I would say we sometimes end up with quite a lot of transient people because they come and get a job and then there’s trouble with getting accommodation and stuff, and they have to move on… (Storyteller 9)

Responsive practice has equally been demonstrated as rural nurses responded to the COVID-19 pandemic. These nurses collaborated with health professionals to ensure adequate care for patients was offered but in different innovative ways. We can acknowledge the pioneering spirit associated with rural nursing practice from Aotearoa New Zealand continued in a similar vein as to the changing health care system identified in the larger research project. This often-involved nurses, health workers and more broadly local authority Council taking on responsibilities outside their normal duties to keep communication lines open and work closely together as highlighted in this excerpt:

… very early on in the piece realised that patients weren't going to come see us… because of their own fear around contracting COVID in the practice. So, we activated a project called COVWELL, which basically is a COVID wellness… made these phone calls to all our high risks patients. This was about a 7 or 8 minute phone making sure they were well, that they understood, if they needed to go into isolation what that meant and what it looked like, making sure they had support around them… for them to know that actually you are on the end of a telephone if I do get sick…

(Rural Nurse, podcast 46).

Rural nurses enhanced their practice as community educators and effective collaborators with a variety of local colleagues and members of their rural communities, drawing attention to community resilience and the progressive rural nurses' pioneering spirit.

4. Conclusion

The health care system in Aotearoa New Zealand during the 1990s was subjected to major economic and a change to delivery models, especially in rural regions influenced by neo-liberal political philosophy [3]. Rural nurses put a stake in the ground with the aim of responding to these changes and enabling equity – exploring new practice models to ensure that the best levels of healthcare were available. The aim of this chapter has been to report on a research project that set out to capture the unique stories from rural nurses from Aotearoa New Zealand with the aim to make visible their practice. Narrative inquiry has provided a depth of meaning to the rural nurse experience and uncovered the discourse of rural nursing in New Zealand in the twenty-first century adding to the international rural nursing discourse. Narrative inquiry methodology recognises the power that story has, to explore meaning, make connections, entertain, and build empathy and share with others. This methodology has provided a depth of meaning to the rural nurse experience; the data analysis and research findings demonstrate that rural nurses have maintained and, in some cases, improved the health care of these rural communities in Aotearoa New Zealand. This rural nursing discourse identified in this research identifies the rural nurse with pioneering spirit; as an entrepreneurial practitioner involving what nurses’ express, as the ‘rural way’. From their innovative practice emerged the contemporary identity of the nurse practising in the rural context which has uncovered the discourse of rural nursing in New Zealand in the twenty-first century and amplified rural nurse voices. This pioneering spirit initially identified in the 1990s has continued in a similar vein, during the COVID-19 pandemic into the 2020s. It is now timely to add to the international dialogue a specific New Zealand discussion and discourse.

Acknowledgments

The authors wish to thank the rural nurses who gave up their valuable time to share their stories and agreed for them to be published in Stories of nursing in rural Aotearoa: A landscape of care. Sincere thanks are extended to our colleagues Raeleen Thompson and Rachel Parmee for their dedication as they also interviewed rural nurses as part of this research. Further acknowledgment is extended to Otago Polytechnic, Dunedin New Zealand for contestable funding in support of this research between 2016 and 2021.

Conflict of interest

The authors declare they have no conflict of interest.