From heart attack to rural and remote nursing – exciting guide

Meet Nikole, a nurse of 16 years from Victoria. From ICU nurse to working in upper management in disability/healthcare, to rural & remote nursing, Nikole’s 16-year nursing career is pretty phenomenal. In this article Nikole sheds some light into her career and insight into all things rural and remote nursing, invaluable to anyone thinking of a change of career trajectory or just wanting to know more about life in the bush!

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Where do you currently work and what are some fun facts about you?

Currently, I work for Healthcare Australia as a Rural & Remote Nurse. Prior to that, I was in management roles in the Disability & Healthcare sectors, and before that an ICU nurse.

I am currently trying to teach myself how to play the Ukulele by watching YouTube videos … it’s not going well! I picked that instrument because it’s small and lightweight, perfect for someone who is on the road a lot.

I have two dogs, Barkly and Oliver, and a cat named Lavender. When I’m on the road working, my kids (24 and 22) look after them at home.

What inspired you into rural and remote nursing?

Rural & remote nursing was something I have wanted to do for pretty much my whole nursing career. Then, in 2019 I had a heart attack. I was very lucky to live so close to a Metro Hospital. I had to make a lot of lifestyle changes, one of which was reducing my stress levels, and that meant moving away from the upper management role I was in. It was actually my 22-yr-old son who encouraged me to go back to clinical nursing and try rural & remote nursing “before I get too old.”

I had a contact at Healthcare Australia that I had worked within a previous role, so I gave her a call and she put me in touch with their amazing rural & remote team. Before I knew it, I was on a plane to Perth where I was quarantined for 2 weeks before heading to my first contract in Carnarvon, WA.

Where have you rural and remote nursed so far?

My rural and remote nursing has taken me to some pretty amazing places.

• Carnarvon – After Hours Manager

• Burringurrah Aboriginal Community – RAN

• Three Springs – Clinical Nurse Manager

• Meekatharra – Clinical Nurse Manager

• Bruce Rock – Shift Coordinator – Emergency Department

• Fitzroy Crossing – Clinical Nurse manager, Community Health

• Howard Springs International Quarantine – Team Leader, International Zone

How does someone become a rural/remote nurse?

The pathway into rural and remote nursing is different for everyone. It will depend on your previous experience and qualifications, and also on what the facility requires. Because of the nature of the work (often working without a Dr onsite, or with a Dr via TeleHealth in remote areas) you need great assessment skills and the ability to make solid, evidence-based clinical decisions. Although not an absolute prerequisite, most facilities require either ICU or Emergency experience, with a post-grad being very well regarded. Add on your standard ALS (Advanced Life Support) and triage competencies as well.

There is also a current desire for rural & remote nurses to also be qualified immunisation nurses due to COVID-19. There are some other courses that are very well regarded (REC & MEC) but these are not always mandatory. CRANA is a great resource if you’re considering rural & remote.

If you want to get into rural & remote nursing, your first priority should be to do some reading and also chat to a nurse that has worked rural & remote (and of course The Nurse Break is perfect for that).

Once you’ve done your reading, you need to sign with an agency. Be picky. Don’t be shy in asking questions, and if you need to, you can ask to be put in touch with a nurse that is currently working for the agency you are considering signing with. There are a lot of agencies out there, all trying to fill the same vacancies, so do your research in terms of sign-on bonuses, education allowances, and travel/quarantine assistance).

Be aware that there are some agencies that will “gild the lily” in an effort to place a candidate, i.e., they will not be totally forthcoming or honest about the facility. Thankfully I have never experienced this, but in talking with other rural nurses, I know it does happen.

Once you are on contract, you will meet other agency nurses at these facilities. Ask them who they work for and if they are happy with the agency. You can sign with more than one agency, and many nurses do choose to do that, but that doesn’t work for me. I love my agency and the support they give me and being with more than one just feels messy and complicated for me, but it is a personal choice, and you will work out what you’re comfortable with as you go.

When I am considering a contract, I do some googling around the location, what there is to do on days off for sightseeing, etc. I join the local Facebook groups to get a feel for the community. I also look at basics, like what the community is like or the shopping for food, etc. Look for a location that appeals to you, and that you feel will be a good experience. Don’t forget to factor in the cost of living, as this can sometimes be a lot higher than you’re used to, especially when you’re just starting your rural & remote journey. Fresh produce in some of these remote areas can be either expensive or non-existent.

What skills as an ICU nurse did you NOT have/had to quickly learn?

This is such a great question, and one that deserves to be discussed. As an ICU nurse who also works in ED, you would think that this would be the “gold standard” for rural & remote work, right? It’s certainly very well regarded by rural and remote facilities, but it means that you potentially have nurses who have only ever worked in controlled metropolitan hospitals, who then find themselves in a remote clinic with no Dr, and none of the normal bells and whistles they are used to.

Critical Care nurses are great under pressure, and normally have really well-developed assessment skills, but that doesn’t really help you when you have an 8-year-old with scabies in the clinic, or a young person with a sexually transmitted disease. What treatment do you give for scabies? How do you have a difficult conversation with your patient about an STD? What’s the protocol for treating a First Nations patient who wants to try bush medicine for 48 hours before they go with more ‘modern treatments”? How do you deal with a school full of children with school sores?

In the current climate of a global pandemic and a shortage of nurses, especially in WA and the NT, a lot of facilities are really desperate to keep the doors open and will gratefully take any nurse that’s willing to turn up and work. This can lead to an inappropriate skill mix in some really vulnerable communities.

I was lucky enough to start my rural & remote journey at a rural hospital, with excellent clinical backup and doctors on staff. From there I went to a remote clinic with the backup of another experienced RAN.

What areas of nursing did you have to upskill in to work rural and remote?

Sexual Health, paediatrics, and maternity were definitely areas I did not have a wealth of experience in, and I quickly realised I needed to upskill in that area. In Carnarvon, I was so fortunate to have the experience of some wonderful midwives, and nurses with paediatric experience. Being from Melbourne, where there are dedicated paediatric ED nurses and paediatric ICU’s, I just didn’t have the exposure. In rural areas you just deal with what comes through the door, man, woman, child, or goat (yes, I once had a goat enter the clinic!).

I will give a big shout-out to Lauren and Paul (you know who you are) for being such generous teachers. I’m a lot more confident now with both kids and pregnant women. My old motto used to be “No babies, No vaginas” ????, but not anymore!

The first time I had to triage a woman in labor, I had to search my memory for questions I was asked when I was pregnant with my children and searching the memory bank for lessons from my undergrad. Not ideal! Fortunately, after the ED staff had a giggle at my clumsy attempts, they let me know I could just call the midwife on the ward who would come and assess midwifery patients.

In the more remote clinics, you need to be able to do this yourself, so I hit the books and did some online courses in preparation for my more remote contracts, but I ended up using my newfound knowledge much sooner than I thought.

The first was a 6-month-old baby who was bought into the ED. As one of the afterhours managers, I was called to the ED to assist when there was an urgent case or an ambulance etc. Luckily, I had just finished doing some extra study on triaging babies and children, and right away recognised that he wasn’t engaging as he should be and was really working hard to breathe. I triaged him quickly and put him straight into a bed.

A few minutes later I was called to the RESUS bay by the Dr, who was placing an IO (Intra Osseus access) into the baby’s leg. The situation deteriorated rapidly, and we ended up having to intubate the baby and arrange for the RFDS to transfer out. That was the start of an 18-hour shift for me, where we would end up intubating 3 patients in one day and 5 intubations in total over a three day period.

The second was also a baby, who was bought the ED of a small MPS site I was working in. No Dr coverage and the other nurse on shift was a new grad. The baby was peri-arrest and I had to work very quickly to stabilise her, while giving instructions to the grad nurse to get the ETS (Emergency Tele Health) Dr on the screen.

In the middle of it all, we had a ‘surprise admission’ arrive via St John’s Ambulance. I say surprise because the transferring facility had forgotten to call and let us know the patient was on the way. I had to call the amazing support services staff to assist with the admission while I treated the baby. Thankfully we were able to get her stabilised and transferred out with the help of the RFDS and the amazing ETS Dr.

What did you take with you when you did remote/rural shifts?

Most of the remote clinics are very well stocked because they have to be! You literally deal with everything from a snake bite, to chest pain, to head lice to road trauma, so you need to maintain your stock and equipment.

I do travel with my own nursing bag though, and it has the usual stuff in it like my own trauma shears, a sat probe, my own stethoscope, and some other odds and ends, like the current NIP immunisation schedule (sometimes the internet is down, or the power is out so it’s handy to have a written copy). I also carry a strong bug repellent and a high SPF factor sunscreen.

What differences do you notice between remote health and metropolitan health care?

The differences are huge as you can imagine. Most medical staff in urban/metro areas have no concept of how different it is. I explained it to some old ICU colleagues like this; Imagine all the ICU’s on the east coast of Australia are in Melbourne. Now imagine you live in Cairn’s, and you get sick and need to be admitted to ICU. That’s what it’s like working in WA. The sheer size of the state is mind-blowing and I had to rapidly recalibrate, and my first shift as the after hours manager at Carnarvon helped do that!

I was called to the ED to assist with a chest pain patient that was coming in via ambulance. I arrived to ED as they were coming in through the ambulance bay. That was when I recognised the ambulance officer as the lady who had cut my hair the day before (remember I had come directly from a Melbourne lockdown and 14 days quarantine, so a haircut was high on the agenda!!). I quickly realised that the WA ambulance service was all volunteers, who do an amazing job by the way.

The patient had ST changes, so I opened my after hours manager folder, flicking through pages looking for information on how to call in the on-call team for the cath lab. When I locate the list, I asked the ED Dr where to find it. After she stopped laughing, she told me that there is no cath lab and that we push clot-busting meds and then transfer them out via RFDS. Thankfully the RFDS wasn’t too busy that day and the transfer time was fairly quick.

That was definitely not my finest hour, and I still get people joking with me about that over a year later!

Another example that comes to mind was a young guy in his mid 20’s from Meekatharra who had fallen and had a suspected fracture of his forearm. I say suspected because we couldn’t do an x-ray as none of the current staff were trained. Let that sink in for a minute. He got flown to Perth because he needed an x-ray. A huge expense! Road transfer wasn’t an option due to the length of the trip and his pain level. There are no lovely well-paved highways to transfer by road at some of these locations.

Can you tell us about any interesting patient cases you’ve had?

How long do you have? I think part of the appeal of rural & remote nursing for me IS the absurd mixed in with the critical/trauma and the funny situations you can find yourself in.

I think the most absurd situation I found myself in was ‘triaging’ a goat while working at a remote clinic in Burringurrah. We could hear a weird banging on the front clinic door, and when I went to investigate, I opened the door, and a goat came charging into the clinic. The goat was very vocal, and it was a hot day, so myself and the other RAN decided he was dehydrated. We gave him some water and he still wasn’t happy, so I fed him some biscuits out of our stash. He ate the biscuits, pooped on the floor, and then ran out as fast as came in. He definitely went down as a DNW (did not wait)!

Burringurrah was also the place where we had to drive the Ambulance (the good old Toyota Troupy) onto the airstrip to scare away any animals before the RFDS landed. Not something you have to worry about in a metro hospital.

When I arrived in Meekatharra, I was just in time to be drafted onto the Police/Nurses/Teachers AFL team, where we played against the locals. At 5 foot 2, the captain of our team (The Police Sgt) thought it would be funny to put me at Full Back. Safe to say I spent most of the game hiding behind the Centre Half Back!

At one stage, after a rushed behind I had to kick the ball back into play, and I managed to kick the ball straight into a man on the mark. Judging by the laughter from the local kids and the opposition players, my contribution to the game was more comic relief than athletic prowess ????.

Some of the more challenging and/or interesting cases were a patient who was heavily alcohol affected and had been bitten by a snake. It’s very difficult to keep a drunk guy still so the venom doesn’t spread. A traumatic finger amputation from a hockey puck, of all things, was certainly interesting. I’ve never seen a mechanism of injury quite like that.

Joking aside, one of the things that is certainly hard to deal with in rural and remote locations is the times where you will have the victim or victims and the perpetrator all in the same facility. It becomes a logistical exercise to ensure that patients are not further traumatised by the presence of the perpetrator, and that you don’t have a hostile escalation to deal with.

I was unfortunately involved in a couple of very serious incidents where this became a factor. Due to privacy, I won’t disclose the locations, but in both instances, the staff were faced with some of the worst kinds of assaults/violence and having to support and treat the victim while also having to treat and provide care for the alleged perpetrator. Often due to the remote locations, there are extended lengths of stay while detectives and forensic staff are flown in or drive into site.

When you are faced with these situations, your biggest asset is your support network and other emergency services. Local Police in these remote areas are amazing. As is the support from either employer EAP or the Bush Support Line. Resilience is great, but debriefing is a critical way to deal with these situations and ensures that you are looking after yourself as well as your patients.

What are some things you would ‘warn’ future nurses BEFORE starting rural and remote nursing?

I would say the key thing to remember is that your idea of healthcare and your patient’s idea of healthcare can be vastly different. Understand the cohort you are working with, how they view healthcare and what is important to them. Traditional, or bush medicine is still widely used in a lot of remote communities and should be respected. Some remote communities place more emphasis on family and community issues than they do on their own health, as is their right. They may prioritise an elder’s funeral over keeping a dialysis appointment.

Gain an understanding of what delivering healthcare looks like in a remote setting and how that differs from your expectations. You need to readjust your goals of care based on what your patient is telling you. You need to think ahead in terms of diagnostics and access to medications. Often meds and supplies are only flown in weekly or fortnightly, so you need to ensure adequate supplies of medications for clinic patients, as well as stock like iStat cartridges that allow you to run basic bloods.

I had to very quickly remind myself that some of these patients don’t have the access or the means to access healthcare like you are used to. A patient may have an appointment in a bigger town for treatment or check-ups but may lack the means to get there. An understanding of how the community priorities time and resources is essential and being able to work with that without judgement.

As a mother, how have you juggled having a family and rural/remote nursing?

I am very grateful to have two amazing children (who are grown adults now) that fully support me and in fact encouraged me to take off on an adventure in the middle of a pandemic! The kids have kept the household running, the animals fed and the house (relatively) clean, while I’ve been travelling. They even surprise me every now and then with the delivery of a care package.

We catch up regularly via facetime for video chats when I’m on contract, and when I am home, we make the most of our time together. Doing this kind of work has a way of making you appreciate what you have, and how you spend your time.

Why is humour so important and can you tell us about some funny moments you’ve had?

Humour is essential if you ask me. I’ve always been known for my “quirky” sense of humour, and I think it’s definitely an asset in rural & remote nursing. You are often in facilities that run on skeleton staffing, and people are tired, burnt out and looking for just a little relief. A good laugh is essential and is a great way to ease tension and help people de-stress a little.

When I accept a contract and work with these amazing staff, the least I can do is be pleasant to be around, and I think a good sense of humour assists with that. 

I’ve definitely found myself in some absurd situations during my time as a rural & remote nurse. Triaging that goat is of course a career highlight, along with sitting at a roadworks “stop here on red light” signal for 25 minutes in the middle of absolutely nowhere on a dirt road, with not a workman or another car in sight, only to realise that a herd of cattle wandering towards me down the road had triggered the red light. So essentially, I waited 25 minutes for some cattle to wander along the road towards me.

Most memorable moment so far?

My most memorable moment so far would have to be the drive from Carnarvon out to Burringurrah. I had only been in WA a week when I was asked if I could urgently head out to the clinic as one of the RANS had to leave unexpectedly for a family emergency.

One minute I was in quarantine in a nice Perth hotel, and the next minute I was driving on a dirt track in the middle of nowhere, with nothing but red dirt and blue sky, headed to a remote community with no shops, no petrol and dodgy bore water. It was one of the most profound experiences I think I’ve ever had. It’s hard to explain the feeling, but it’s one I won’t ever forget.

Top 5 pieces of advice for a nurse going out first time rural/remote?

1. Pack what you think you need and then put half of it back. Especially if you’re flying to your contract. Some of the luggage limits on regional flights are brutal. And they will leave your bag behind for another flight if they are over weight. Speaking from experience, you don’t need 11 pairs of shoes (especially when you forget to pack socks)!!
2. Do your research on where you’re headed. Know the community and know what the current health issues are.
3. Take a sharp knife and your pillow if you can. It will make all the difference. A lot of nursing accommodation kitchens have crappy knives. If you’ve just paid $15 for a punnet of cherry tomatoes, you don’t want to be squashing them with a blunt knife.
4. Go with a reputable agency and keep in touch with them regularly. Don’t accept unsafe conditions or pressure to work outside your scope. Let your agency do the negotiating and sorting out of issues. Keep them informed. They can’t support you if they don’t know what’s happening.
5. Have fun. I know it sounds cliché, but if you’ve made the transition and you’re out doing remote and rural work, don’t forget to see the sites! Australia is a gorgeous country and there is so much to see and do.

What’s next for your career?

Currently, I’m at home in Melbourne for a couple of weeks rest. After a year on the road, it’s great to come home and recharge for a bit. Next up I’ll be headed to Wimmera Health ICU for a short contract over Christmas and New year, and then the current plan is to do a contract in NSW/QLD. But if there’s one thing I have learned doing rural & remote nursing, it’s that you never know what’s next. Embrace the uncertainty and say yes to adventure!