A study of the primary health care identity work of Australian rural nurses in a context of national health reforms

This thesis is an investigation into primary health care (PHC) nursing in Australia, focused on the interface between nurses, their health organisations and the local community. It is set during a period of significant cultural and structural change informed by the move towards a National Primary Health Strategy within health reform. Nurses, as the predominant health workforce in community settings, are pivotal to governments’ health reform agenda; however there are tensions evident with different groups, with different expectations and interests, positioning nurses as providers of PHC. The aim of this study is to explore nurses’ agency through identity work to inform an understanding of contemporary rural PHC nursing in Australia with a focus on how control and agency are evident in PHC nurse identity work. Using a Critical Realist theoretical perspective, an explanation of PHC nursing identity, as a social structure, is presented through analysis of the interactions between structure and agency within a social, cultural and historical context. Expansion of the role of General Practice is an integral component of the PHC reforms. Historically, Federal Government incentives to increase the number of nurses in these settings were provided to rural General Practice settings. Rural communities experience significantly higher burdens of disease in comparison to urban settings coupled with difficulties in recruitment and retention of health professionals. Therefore, PHC nursing within small outer regional communities provides a distinct and relevant context for this study, given these changing health service environments. Two forms of empirical data were gathered which reflected PHC nurse identity work at different levels. The first data source consisted of 265 publicly available documents submitted to the National Health and Hospital Reform Commission to inform the draft National PHC Strategy. These documents, as texts, reflected PHC nurse identity work at a broad national level by key groups with an interest in positioning nursing within PHC. Transcripts of interviews with 21 rural nurses working in various PHC settings in two Australian States provided the second source of data, reflecting identity work at the level of individual PHC nurses. Content analysis of the public submissions and thematic analysis of the interview transcripts provided evidence of PHC nurse identity work. Nurses’ individual interests were predominantly focused on the local context of their clients/community and their local health team through a broad range of nursing roles. Organisations representing government and medical interests emphasised particular nursing roles, and focused on the allocation of funding resources, structuring of medical leadership and support for those roles. There was evidence of nursing’s attempts at developing collective agency as PHC nurses. However, resource allocations for and managerial control of particular nursing roles in PHC evidenced ambiguity regarding PHC nurses’ collective agency in being able to effectively meet the interests of rural nurses in providing PHC for their clients/communities as autonomous health care providers. Synthesis of the evidence derived from analyses of the two data sources revealed four main identities for PHC nursing in use within rural health services; The Doctor’s Nurse, the Local Community’s Nurse, The Organisation’s Nurse and the Boundary Spanning Nurse. Diverse interests, including those of individual nurses, broad community groups, health organisations (including nursing and medical groups) and various levels of government in Australian society, were reflected in these identities. Based on the findings and using Critical Realist theory to underpin the exploration of the empirical data, an explanatory framework is presented incorporating the four main identities. Agency and identity allow the complexity of the nurse/health service/community interface in a cultural and structural context to be incorporated into this qualitative empirical study. Ambivalent representations of nurses’ autonomy as providers of PHC within the primary and community care framework have implications for nursing practice, the provision of PHC nursing for rural health services and sustainable PHC reform. Ongoing tensions and difficulties are likely to continue without structural health service changes which enable nurses to provide client/community focused care as autonomous health care providers.