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Sandy Bell is a Rural & Remote Nurse Practitioner. She has written the most in-depth article on all aspects of the role, stories and experiences, lessons learnt, tips, advice and more. From shark bites, rollovers, amputated limbs through to primary healthcare – she has gone into full throttle with this article to give you an extremely down to earth perspective of being a Rural and Remote Nurse Practitioner!

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Tell us about yourself and how did you enter nursing and why?

For some people, their health career goes directly from A to B in a beautiful straight line, however, my health career has gone from A to Z in a very squiggly line that sometimes resembles a toddler’s drawing!

I started nursing straight out of school; I was not sure I wanted to be a nurse; however, I didn’t know what else to do. I was accepted into a Bachelor of Nursing at Bathurst in NSW after finishing year 12, but I was only 17 and there was no way I wanted to leave my boyfriend at that time, so I deferred uni, and completed Enrolled Nurse training at Goulburn Base Hospital instead.

I then went on and completed Mothercraft training in Sydney and worked as a Mothercraft Nurse for a couple of years before I headed overseas and worked as a nurse/camp counsellor in American summer camps and then as a live-in mothercraft nurse in London.

When I returned to Australia, I finally knew what I wanted to do, and that was to be a paramedic. I applied a couple of times, (unsuccessfully), and then was finally accepted on the third application with NSW Ambulance Service. In those days, the training was initially done in Rozelle, Sydney and then we worked on ‘the road’ during our probation period.

I worked as a paramedic for about 10 years, working in metro, rural, and northwest and far west NSW. During that time, I also completed my Bachelor of Nursing and eventually made the decision to change careers back to nursing, because at that time, as an ambo, there wasn’t an opportunity for family-friendly hours for me as a single mum.

From there, I worked in a rural RN casual pool for a few months, until I saw a 6mth contract being advertised for a remote area nurse in WA; I applied and was super excited to accept the job. I literally packed up my life and drove to WA from NSW with my son, who was 4yo at the time, in a little Hyundai Excel with no air-con during an extremely hot December….and let’s just say there were times on that trip where we were both in tears….

When we got to WA, I started my new role as a remote area nurse, (RAN) with part of my role also being the HACC co-ordinator. It really was a brand-new type of nursing for me, but my experience as an ambo was incredibly beneficial as it meant I could handle both major trauma and critically unwell patients with no stress and almost as second nature, which was especially helpful as we were 4 hrs from the nearest hospital and RFDS could take hours to get to us.

Working as a RAN is where I also recognised the huge need for advanced, holistic health care in remote communities, and decided that the best way I could provide this holistic, ‘one-stop shop’ nursing was to become a Nurse Practitioner. I completed my Master of Nursing (Nurse Practitioner) in 2010 and have not looked back since!

You have spent the last 15 years in remote/primary health and 10 years as a Nurse Practitioner!

The role of a remote NP literally encompasses everything and is one of the most rewarding jobs I have ever done! When working as a remote NP, a typical day will cover anything and everything. When asked about the types of presentations I might see I answer with, “if you look at the directory on the wall in a major hospital, then that is what I may see on any given day”.

Most of my time working as a remote NP has been in remote communities in WA, in the Gascoyne, Wheatbelt, Midwest regions. When health care workers think of working in remote communities, they will most likely conjure up the image of working in remote Indigenous communities in the red desert lands, but I always like to remind people that remote nursing can also mean working in offshore rigs, working in geographically remote mine sites, or on islands, or in remote non-Indigenous communities.

Do you have much autonomy?

Working as a solo nurse in remote areas means you need to be more resilient and also need to be able to work through problems and solutions autonomously. Even if you don’t know the answer, then you need to know the right questions to ask of the right people.

For example, I remember working on a remote island in WA when I had to do some urgent pathology…. Obviously, the island had no pathology services, there was no hospital, there was no regular transport on or off the island, so I had to consider how to find a solution to the problem. I asked some of the fishermen how they get things onto the island if urgently needed and this enabled me to consider how to get things off the island urgently.

I was then able to organise for a passing small charter flight to stop by the island and gave the pathology to the pilot to take back to the mainland where I organised a colleague to go the airport on the mainland, pick up the pathology from the charter plane and take the pathology to the hospital for me. The ability to think outside the square is super important when working remotely.

At the end of 2019, I decided to leave my permanent NP role in a small community in WA and take time out for me, which is awesome because at the moment I just do short term contract work as an NP. As well as continuing to do remote contracts, I also work casually in a rural NP led after-hours walk-in centre, I do rural NP influenza vaccine clinics, I recently did a stint on Hamilton Island, and I also do some casual work as a RN in the COVID workforce in the Perth Quarantine hotels.

I am absolutely loving the freedom of working where, and when I want; and what a great way to see new areas, to work with fantastic nurses, and to be able to make a huge difference to patients’ health stories in so many places.

What are some unique aspects of your Scope of Practice?

Being a remote NP means that my scope of practice is broad – very, very broad. Obviously, I am also bound by legislative requirements in different states, and I won’t prescribe for things that I have little knowledge about. As a remote NP, you really are the jack of all trades, so you develop a broad knowledge and experience base. This is also reflected in my CPD, much of which is targeted, where I will complete courses in trauma, emergency and disaster management, chronic diseases, preventative care, investigative procedures, as well as things like minor surgical procedures.

What does a typical day look like for you?

In a remote clinic, typically the day will start with doing the clinic equipment and drug checks then I am straight into seeing patients non-stop all day. For non-urgent presentations, pt’s are encouraged to make an appointment and I prefer to run clinics with appointments so that I can utilise my time effectively, and not have pt’s waiting in a clinic for hours.

During the day I see anything from people wanting a repeat script for their chronic conditions, to people needing a referral to see a specialist, to someone who needs an annual health check, to diagnosing and working out a plan of care for things like diabetes, hypertension etc, to doing kids health and vaccinations, looking at skin conditions, doing any health promo programs I am running at that time, and then in between all that will be those acute and/or critical presentations that may include absolutely anything from MVA’s, to boating incidents, to general sickness and then all the usual ‘coughs, colds and sore holes’.

At the end of the ‘clinic day’, I have to go through the pathology results and action as appropriate, review any specialist reports or referrals to me, and finish off any outstanding research that may be needed to assist a pt. After that, there is the usual gazillion emails to go through; I am then on call overnight and start the whole process again the next day.

What are the main types of patients you see?

The types of patients I see include everyone across the lifespan with any disease, illness or injury. This may include farmers, fisherman, lots of grey nomads, local families, or those living in the area who also have the related lower socio-economic issues, or those hiding in remote communities to escape government organisations such as Centrelink or Child Care payments, so pretty much any and all types of patients.

In the role as a remote NP, I am often the fundamental primary health care provider, as there is generally no other health care providers for patients to see. I will collaborate virtually with specialists, colleagues and other health care providers, facilitate appointments or telehealth and do what I can, where needed, to offer a team approach to health care, (usually in a virtual capacity).

What are some stories you can share?

Like lots of nurses in this job, I don’t always remember patients I have seen or what jobs I have done…sometimes I even forget who I have seen just that morning…. however, we all have jobs that do stand out….

One job I remember well was when I was working in a remote area on Anzac Day where all emergency services, e.g., police, volunteer ambos were at the Anzac 11am Service. Right at 11am, just as the Service was commencing, phones started going off everywhere…there had been a serious MVA about a 2hrs away with people still trapped. I raced to the clinic, grabbed all the emergency gear, and headed to the scene in the police car to find 2 people out of the vehicles and one still trapped.

The person trapped, was the driver of one vehicle who had been driving with their arm outside the window when their van rolled. This patient was still trapped in the driver’s seat with the vehicle on its roof and their arm somehow compressed between the road surface and under the roof of the vehicle.

I was able to insert a cannula in the patients other hand by sliding myself halfway into the vehicle and could start IV fluids and analgesia, as well as airway management whilst we had to work out a way to lift the vehicle off the patient. In remote areas we often do not have rescue services available… so in this case we had to wait until we could get a tow truck with a lifter to slowly lift the vehicle off the patient’s arm. Once the vehicle was lifted, we were able to extricate the pt and provide more lifesaving treatment. As we were removing the pt, one of the ‘bystanders’ also collapsed, as the temperature was in the mid 40’s that day and it was super hot on the road.

We then transported the pt with the volunteer ambos to meet a RFDS plane at a nearby roadhouse airstrip. Whilst waiting for RFDS, I was able to provide further medications, applied dressings and tourniquet to the pts’ almost completely amputated arm, maintained spinal precautions, inserted an IDC, and reassured the pt. The pt was transferred to the state trauma centre and they did survive, but sadly lost the normal use of the lower half of their arm.

I also recall multiple jobs where I have had to get on marine rescue vehicles to assist with people injured in the water after boating incidents or being washed off cliffs. Those type of jobs often result in loss of life and this can be gut-wrenching when picking up the survivors. One particular ocean rescue still haunts me, as the sea was so rough and the swell was massive, I remember literally sitting on the floor of the rescue boat holding on for dear life with two of the other rescuers on our boat vomiting non-stop due to seasickness. I was cursing myself that I had forgotten to grab the satellite radio, which meant I couldn’t even call my boss to ask her to advocate to the water police to get us back to shore, as it really was an incredibly dangerous situation.

I also have great recollections of patients who I know I have literally made a massive difference to their life and their health journey by diagnosing and treating chronic disease, or suggested effective treatment for an illness or even by providing comprehensive education and this genuinely makes my chest puff out. I really love the thank you letters that have a theme of “the most thorough assessment I have ever had” or “even my doctor has never checked for that”. I also absolutely love when I get cards or drawings from children who have been injured or really sick and have made a full recovery.

 My son, who has now left home, often tells me he misses his share of the chocolates that I would often bring home from grateful pts…. I now quite often send him photos of chocolates just to brag…Every nurse loves to feel like they have made a difference and to feel appreciated, and when this happens it makes the job even more amazing!

What qualifications do you have to allow you to be a Rural & Remote Nurse Practitioner?

The qualifications required for my role included Bachelor of Nursing, (obviously), then I needed at least 5 years experience in my speciality, as well as a Master of Nursing, (Nurse Practitioner), and to be able to demonstrate competence and confidence in my speciality area, which is remote and primary health. Along with these, I also have a couple of degrees in pre-hospital care, as well as some post-grad certificates in pre-hospital related fields, as well as a post-grad certificate in point of care studies and a post-grad diploma in rural health.

I also have current ALS, current immunisation certification, advanced MIMMS, as well as all the usual remote certificates such as MEC, AREC, EPNC and TNCC. For a while there, I am sure my family thought I was some sort of study freak….

I absolutely encourage every single health provider to always continue to learn, to update their skills and knowledge and regularly update qualifications. It really is not ok to have an attitude of “I’ve been doing this for years”, without keeping up to date with your education, and it’s great to be able to provide evidence-based best practice care to every patient, every time. And the amazing thing is, we are so lucky that there are so many cheap or free learning resources available these days!

What are some of the essentials to carry when working?

Some of the essentials I carry close by whilst working are the usual basic stuff like gloves, tape, scissors… I also carry a stethoscope, pen and paper and reference cards. Our emergency equipment in remote clinics includes an oxy viva, Zoll manual defibrillator, emergency drugs including ALS drugs, S8 analgesics as well as things like midazolam, acute cardiac drugs, and corticosteroids. We also have an ‘emergency bag’ that we take to emergencies out of the clinic, which has things like cannulation gear and fluids, advanced airway equipment, IO gear, maternity equipment, the usual first aid stuff like trauma dressings, bandages, snake bite treatment etc.

What clinical foundations should nurses have before they consider going remote?

There are some fundamental skills nurses must have before going remote, and remember remote nursing is different to rural nursing!!

Most importantly nurses need to have common sense and be able to think outside the square. They absolutely must have an extraordinarily strong assessment and communication skills, strong primary health experience, as well as ED skills. I often hear of nurses with limited experience believing they will be fine working remote, but you need to remember when you are in the remote field that you, and you alone, may literally be the difference between a person living or dying.

I know this sounds melodramatic, but if you miss something in your assessment, or you do not communicate accurately to the dr/RFDS/etc, your patient may die. I always explain to nurses who may not have an understanding of this concept by saying, “imagine if your friend or family member was travelling in a remote area, what if they had a cough and shortness breath, and you missed their acute pulmonary oedema in your assessment, this can be fatal”.

Or “someone you know has a serious MVA, you are the only qualified health care worker, and if you do not have the skills to treat major trauma or recognise the risk of, (for example), hypovolemia from a # pelvis, then yes, this person may die before reaching tertiary treatment”. This is a harsh description, but it is the reality.  I know there is always robust debate about whether RAN’s need ED skills and although a large portion of our work is chronic disease related, I personally feel ED skills are definitely needed.

It is also important to consider where you are going in relation to what skills are of paramount importance. For example, if you are going to a small remote clinic that is in an area renowned, (for example), for activities in remote sand dunes, then obviously ED and trauma skills are an absolute must to deal with things like sand dune buggy rollovers. If you are going to a larger clinic where there will be senior staff to support, you then you may have the opportunity to develop skills as you go, and this is fantastic!

If you are going to a community where RHD or renal failure is prevalent, then obviously you should ensure your skill base meets what will be most commonly required in that community. If you are going to a remote fishing island where most of the residents are young and healthy, then your required skill set will differ again. Regardless of where you are going, you still need strong assessment skills, primary health, as well as some ED skills, especially if you won’t have the support of more senior staff with you at all times.

What are some of the health disparities you see in your practice (rural vs metro)?

Health disparities in rural and remote areas often relate to ease of accessibility to holistic care and this is particularly relevant in chronic disease management. This is where the remote NP role can make the biggest difference.

For example, if a patient presents to the clinic with a sore foot, the foot can be assessed and treated as needed, however, the NP will take it one step further and may also note that the pt. has a high BP –  they then may ask when the patient last had a full pathology workup and order pathology, review the results and in the meantime provide the pt. with hypertension education, organise home BP monitoring, consider and assess for other causes of hypertension and then prescribe an antihypertensive as appropriate.

The NP will then follow the pt. and review and assess ongoing management. In remote areas this type of holistic care may not always be easily accessible, the pt. may need to travel or not have the inclination to even have a full check-up, however by building a trusting relationship with the NP, these barriers can be overcome very easily.

What are the most challenging and difficult aspects of remote nursing?

For me there are two things that are most challenging when working permanently in remote communities:

The first challenge is that you are often seen in the community as the nurse only, and people forget that you are actually a normal human being, with a life outside of work. I’m sure many of you can relate to the very common experience of being in the shop buying your bread and milk, in what should be a quick trip in and out of the shop, but instead, it turns into every second person wanting to ask you health or clinic questions.

Or when people turn up at your home with blood dripping all over your front porch from a wound they have just sustained, and they thought “it would be quicker just to come to your house”!! This is when you need to give some tough love to the community and really set strict ground rules for work vs personal boundaries.

The second challenge is the toll the very long work hours can take on your family and social life. One of the difficult aspects of working remotely is the investment you inevitably put into your role and the community. Although this type of investment or commitment is admirable, it can be completely all-consuming and then coupled with long hours and the on-call requirements, your personal and family life can suffer if not checked.

I look back to when my son was growing up and the number of times, he was left at home alone whilst I was on a call out, or the number of school events I missed, and this can be really tough. My son was super resilient and understanding, and on the flip side I earn a great wage, so we had some amazing holidays. He is incredibly understanding of the benefits of remote nursing, and I also believe his remote upbringing has helped him be the kind, caring and adventurous person he is today.

What is one myth or common misconceptions that you want to debunk about rural/remote nursing?

Myth: Remote nursing is the same as rural nursing, or the terms are interchangeable….. definitely myth!! The two can be vastly different.

What is one thing you wish you would have known before you started your career in this field?

How much I didn’t know!!! I look back to when I started remote nursing and how much I thought I knew; I was so wrong, I had so much to learn!

Can you think of a funny situation you have had while working?

We all have eye-rolling moments multiple times a day and often funny situations. One situation I recall that was not funny as in ha-ha, but a bit comical, was when I was working in a fishing area renowned for sharks but rarely had any shark attacks. I received a call on a Sunday arvo about a guy coming into the clinic from an hour down the coast with a shark bite to his leg.

Of course, my mind thought of the worst and I raced to the clinic and started preparing for major trauma. When the patient and his family arrived, he had a massive bandage around his leg but seemed quite ok, walking and talking and appeared hemodynamically stable. I pulled the bandages off and yes, he did have quite a large shark bite to his leg, but he was very stable. When asked how it happened, apparently the patient had caught a shark on his fishing line, he pulled the shark onto the boat to take a photo and when trying to hold it for a photo, the shark obviously was pretty annoyed so took a chunk out of the patient’s leg.

Why should other nurses or students consider this area to work in?

Remote nursing is so wonderfully rewarding, and it is an area where you will gain amazing skills, knowledge and experience. If you have any interest in exploring our country, or learning more about our First Nations People, or growing yourself more as a nurse and person, then remote nursing should definitely be considered.

What are some thing’s others can do to better prepare themselves to get a job rural and remote?

It is really important to get as much training behind you and qualifications specific to remote nursing as you can. This will help you to be able to provide the best possible care, improve the health of remote communities, as well as literally save lives! If you do take a job in a remote community, do some research before getting there; try to find out about the community demographics, the main industries in the area, the culture of the people, what facilities they have and importantly who is the phone service provider….

If you could talk to a world-leading expert to gain insight on any topic, what would it be?

If I could talk to anybody, I would want to have a long chat with a Station Leader at one of the Antarctic Stations, to find out not only about their role, (which sounds amazing), but also to gain some insight into how people working at the stations during the winter periods stay mentally fit and well in such harsh conditions.

From a health perspective, I would love to talk to an expert to find out more about the process of de-labelling those with a ‘penicillin allergy’. For all the people who report being allergic to penicillin, when we know that the majority of these reports are probably not true current allergies, it would be great to have a nationwide process to address this issue. I understand some work is being done in areas around the nation, but it would be great to find out how the experts think a consistent program could be developed.

If you could change one thing only (anything at all), in nursing/health, what would it be and why?

Hmmmmm, difficult question…… I think I would like ALL nurses to be completely recognised as true, independent professionals and for this to be reflected consistently across all fields in the title, pay, attitude and acknowledgement.

What keeps you busy when you are not working?

What keeps me busy when not working…. life keeps me busy. I have fairly recently moved to the city and do remote contacts based from there, and OMG I love the benefits of living in the city that I have not experienced for over 15years. I love that I can go to shops whenever I want, I love that I am able to catch up with friends in the city or catch up with rural and remote friends when they are in the city. I think the first week I moved to the city I went to Bunnings like every day, and I was also so excited to be able to go to the supermarket to buy just buy one solitary item…rather than doing a bulk shop with a few trolley loads.

One of the things I love doing, (and a bonus of contract work when out and about), is driving down a country road just to see where it goes… and I am even happier if I get to go camping at the end of the road. Basic bush camping with friends or family, with a good campfire, is the absolute best. I really enjoy exploring new places, especially in Australia, but I have also been really fortunate to have travelled extensively overseas as well. I also love snow skiing – although the older and more unfit I become, the less keen I am to go down slopes that look even remotely steep!

Finding a healthy work/life balance can be difficult if working full time in a remote community and it is hard sometimes to find that balance. One of the best things I have done, is to take a step back and to embrace the philosophy of ‘life really is short’ and work is not ‘life’ – but it has definitely taken me a while to get to this spot…… I would suggest to everyone that the new buzz of ‘mindfulness’ should be really taken on board.

My advice for a successful nursing career is to do what excites you and surround yourself with leaders or managers who are passionate about your growth and development. These two things will improve your success in leaps and bounds!

“I have heard there are no job prospects for NPs in Australia, there seems to be no benefit in becoming a NP”

I despair when I hear this, because there are so, so many benefits to becoming a NP.

Yes, I agree the role of NP’s is definitely not as known or advanced in Australia as in other countries, however, the benefits of the NP role are becoming more and more recognised with more and more organisations understanding how NP’s can be such an amazing asset to the team and provide advanced holistic health care. NPs are now being utilised in areas that previously were never even considered, areas like mine sites, border control and Customs boats, speciality areas like haematology, Defence Forces, women’s health, drug and alcohol, wound care, as well as the more well-known fields such as ED, palliative care, aged care, orthopaedics etc. Across Australia there are also many NP’s who now own and successfully run their own private NP business, again showing another exciting avenue for the NP role.

The NP plays a unique, advanced, holistic role in the health care field, a role that literally can change peoples health journey and even their life!

Since becoming endorsed as a NP, I have never once been without work as a NP! There are amazing opportunities at every corner for NP’s and even if some of those opportunities may not be clearly advertised, they are definitely there!

So, my answer is 100% yes there are absolutely job opportunities for NPs, and 100% yes there are so many benefits and positives associated with being an NP!

What are the takeaway key messages that you would like those who read this to be?

I would love for nurses to feel passionate about being able to give the best possible care to every single patient; to understand the absolutely awesome benefits and rewards of working as a Nurse Practitioner, and also for the reader to get some more insight into how amazing it is when working remote.

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