A greater understanding of rural nurse practice will assist in achieving positive care outcomes in an environment with competing stakeholder needs, and limited resources and options for care.

When people telephone rural health services with unscheduled healthcare needs, rural nurses manage these telephone presentations. However, there is professional controversy surrounding the practice, and paucity in research outside formalized telephone triage services. This article reports on a qualitative study exploring the actions nurses take when people telephone rural health services with unscheduled healthcare needs and the factors that influence these actions. Registered nurses from five rural health services in Victoria, Australia, participated in telephone interviews or focus groups during 2010 and 2011. Descriptions of telephone interactions reflected a structured approach to providing care. Participants described strategies to minimize clinical risk while brokering competing needs and finite resources to achieve a "best outcome" for all stakeholders. This study reveals a gap in policy and practice support for rural nurses providing care via telephone and differentiates this rural nursing practice from that of formalized telephone triage.

Anecdotal evidence and a limited body of research suggests that telephone interactions between health care consumers and health professionals form an important part of unscheduled health care provision. However, very little is known about these interactions, particularly in the rural context. In rural Australia, there is a need to explore a range of models of service delivery. Telephone-based unscheduled care is one area that demands consideration. By defining unscheduled health care and delineating telephone-based unscheduled health care from other telehealth services, the concepts of formal and informal telephone-based unscheduled health care provision are explored. This article raises previously unasked questions about the role of telephone-based unscheduled health care in the rural context. As a dimension of health care that is poorly understood, the need for further conceptualisation, research and policy development in this area is highlighted.

BackgroundDue to large geographical distances, the telephone is central to enabling rural Australian communities to access care from their local health service. While there is a history of rural nurses providing care via the telephone, it has been a highly controversial practice that is not routinely documented and little is known about how the practice is governed. The lack of knowledge regarding governance extends to the role of Directors of Nursing as clinical leaders charged with the responsibility of ensuring practice safety, quality, regulation and risk management. The purpose of this study was to identify clinical governance processes related to managing telephone presentations, and to explore Directors of Nursing perceptions of processes and clinical practices related to the management of telephone presentations to health services in rural Victoria, Australia.MethodsQualitative documentary analysis and semi structured interviews were used in the study to examine the content of health service policies and explore the perceptions of Directors of Nursing in eight rural health services regarding policy content and enactment when people telephone rural health services for care. Participants were purposively selected for their knowledge and leadership role in governance processes and clinical practice. Data from the interviews were analysed using framework analysis. The process of analysis resulted in the identification of five themes.ResultsThe majority of policies reviewed provided little guidance for managing telephone presentations. The Directors of Nursing perceived policy content and enactment to be largely inadequate. When organisational structures failed to provide appropriate governance for the context, the Directors of Nursing engaged in protective mechanisms to support rural nurses who manage telephone presentations.ConclusionsRural Directors of Nursing employed intuitive behaviours to protect rural nurses practicing within a clinical governance context that is inadequate for the complexities of the environment. Protective mechanisms provided indicators of clinical leadership and governance effectiveness, which may assist rural nurse leaders to strengthen quality and safe care by unlocking the potential of intuitive behaviours. Kanter’s theory of structural power provides a way of conceptualising these protective mechanisms, illustrating how rural nurse leaders enact power.