Core drivers of quality: a remote health example from Australia.

CONTEXT In July 2005 the National Rural Health Alliance released a discussion paper on advanced nursing practice in rural and remote areas of Australia. The paper called for more debate and research about advanced nursing practice roles, especially on how the roles contribute to quality care and patient health outcomes. Monash University School of Rural Health, Victoria, Australia, completed two studies exploring the role and practice of remote area nurses working autonomously in bush nursing centres in East Gippsland, Victoria. The studies confirmed the nursing role as advanced and expanded, and the care effective and of high quality. The studies also revealed the contribution of the remote area nurse to quality care involved more than demonstrating effective healthcare delivery and evidence based clinical practice. The significance of context emerged as an important determinant. ISSUE Articulating measures for quality care in Australian remote health practice is problematic. The concept 'quality' is multidimensional and time and context specific. Current Australian health service and professional competency standards fail to combine external structural and organisational factors, and the social and economic situation of a given remote community. Together, these factors create the context, and influence practice and remote health service delivery. It is accepted that context shapes remote nursing practice, however the term 'context' is commonly interpreted as an environmental, structural or geographical construct. These terms are valid; however, they do not describe other drivers that impact on remote area nursing and service delivery. In practice, therefore, to what extent does context influence the contribution of remote nursing roles to quality care? LESSONS LEARNED Four core drivers that model the remote area nursing context were identified: the system, the organisation, the community and the individual. An integrated conceptual model consisting of the core drivers is presented, and this provides a broad framework to illustrate factors influencing the delivery of quality remote health care, in an attempt to crystallise the role of context. Central to the model is the remote area nurse. This article outlines the core drivers and discusses how these drivers impact on remote area nursing practice in Victoria and the provision of quality care. The model is transferable to other remote nursing contexts and provides an alternative approach to evaluate the contribution of a remote area nursing role. Enhancing our understanding of the influence of context may assist in identifying relevant indicators to measure the quality of remote health care delivered by nurses in advanced practice roles.