Sandy Bell is a Rural & Remote Nurse Practitioner in Remote Australia. 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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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 are some emergencies and 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.

“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!

Sandy Bell

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!