NRHANational Rural Health Alliance

CATALOGUE SEARCH HELP HOME

RETURN TO JOURNAL PRINT THIS DOCUMENT

Remote nursing services at island tourist resorts

J. Wilks, S. Walker, M. Wood, J. Nicol and B. Oldenberg

The Australian Journal of Rural Health © Volume 3 Number 4, November 1995

Aust. J. Rural Health (1995) 3, 179-185

Original Article

REMOTENURSINGSERVICESATISLAND TOURISTRESORTS

School of Public He&h; Queensland LTniuersity of Technology and Nationul Reference

Centre for Classification in He&h, Queensland University of Technology, Brisbane;

Queensland, ilustrulia

ABSTRACT: Based on a 6 month retrospectke analysis of clinic records> rhe present stud>- reports

a detailed projile of nursing sewices provided for guests at three tropical island tourist resorts. .A

total of 1183 clinic oisits xere anallsed, with presentations coded according to the International

Classification of Primary Care 1ICPCl. T/ le main reasons for presentation zcere skin problems: ear

disorders, respiratory, digestive and muscnloskeletal complaints. Health services consisted mainly-

of medication, specialist nursing cure and fast aid. Study findings highlight the importance of

using an internationally accepted class$cation system for primary health research, and the

critical role of the nurse in tourist health sercices.

KEY WORDS: nurses, remote locations; sew-ice delivery, tourism.

INTRODUCTION

According to Thornton1 ‘a remote area nurse

(RAN) is any RN employed in a community that

is geographically isolated from medical facilities.

The nurse works on a 24 hour oa-call basis, serv-

ing communities throughout Australia ranging

from approximately 200 to 1300 people’ (p. 10).

Despite the difficulties Gth a distinct classifica-

tion of rural, remote or isolated,’ the problems

experienced by both rural and remote nurses are

generall!; similar> and stem from geographical iso-

lation from support systems including peers and

education centres.3

Correspondence: J. Klks. School of Public Health, Queensland Unil-ersit!- of Technology, Locked Bag 2.

Red Hill, Qld 4059. Australia.

Acceptedforpublication June 199.2

In man>- remote areas the nurse often works

alone. el-en if a centre is staffed IX more than one

registered nurse. &cording to Armit, these

nurses haT-e a multifaceted role that includes

medical care: counselling, dealing with social

problems. preT-entir-e medicine and many non-

nursing duties (L. Xrmit. unpubl. data, 1995).

In the late 1970s there were fete published

accounts of the life of the remote area nurse in

Au,stralia. Kth the establishment of the Council

of Remote -1rea Nurses (CR-U-4) more informa-

tion is becoming available, and greater opportuni-

ties for remote area nurses to share their

experiences at annual conferences.A-J

A relatil-ely ileT\- context for nursing services:

and one that has receiI-ed little attention, is the

nurse who is emplo>med at isolated tourist destina-

tions. These positions in the field of ‘tourist

health’ are often perceil-ed as glamorous and

180 ALJSTRALIANJOURNALOFRURALHEALTH

exciting, but the range of services required is as customers, drawing attention to the possible

diverse and challenging as any encountered by health and safety problems that might be experi-

nurses in remote locations. enced during a vacation is not a positive market-

Tourist health is a relatively new field of study ing strategy. Therefore, health and safety issues

concerned with protecting, promoting and restor- are generally not mentioned in promotional mate-

ing the health of tourists both as individuals and rial8 and operators rely heavily on existing med-

as a population group.6 Tourist health therefore ical services and insurance to cover their legal

includes all aspects of medicine (both curative responsibilities should a problem arise.

and preventive), as well as a wide range of public The advantages of having a resident nurse at a

health topics, such as food safety, protection tourist destination include legal protection and a

against injuries, infections and communicable demonstration that the duty of care owed to cus-

diseases. tomers is adequately discharged,7%9-10 profes-

Nurses working at commercial tourist facili- sional health care that ensures appropriate

ties provide what has previously been described treatment of medical conditions and injuries

as a silent customer service.7 While tourist opera- should they arise and finally avoidance of situa-

tors are interested in protecting the health of their tions where a minor health issue could disrupt a

TABLE 1: Nursing stqfSat tropical island resorts on the Great Barrier Reef

Island

lTSOll

No. of Part-lime/

full-time

Other

duties

Clinic

h OUl??

On 24hour

call

Yes

Yes

Hayman

Hamilton ‘i;

3 3 Full No

1 1 Full No

Great Keppel 1

Heron 1

Dunk 2

Brampton

Lizard

Lindeman

Daydream 2

South Molle 2

Green

Fitzroy

Long Island

1 Full No

1 Part Yes

1 Full

1 Part

2 Part

2 Part

2 Full

Yes

Yes

Yes

Yes

1 Full No

1 Part

1 Full Yes

1 Part

1 Full No

1 Full Yes

1 Full Yes

1 Part

9am-6pm

9am-12 noon

3pm-6pm

9am-1 lam

4pm-5pm

9am-loam

4spm-5pm

9am-loam

4#pm-5pm

9an-loam

4pm-5pm

Sam-12:30pm

5pm-7:30pm

9am-11:30am

3pm-5pm

9:30am-10:30am

2pm-5pm

None

None

None

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Clinic

See

Free

$35

$10

$10

Free

Free

Free

Free

Free

Free

Free

Free

$10

Call out

fee

$50

$75

$35

$25

$20

$25

$35

Free

$60

Free

Free

Free

$40

*’ Hamilton Island is the only resort with a resident medical practitioner as well as nursing staff.

REMOTE NURSING AT TOURIST ISLANDS: J. A;ILKI’ ET AL. 181

vacation. The latter issue is one that has emerged

recently with successful legal claims against

tourist operators for disappointment with travel

experiences.ll

Nurses are employed at many of the Great

Barrier Reef island resorts (Table 1). Their

responsibilities generally involve being a\-ailable

on 24-hour call: rumiing regular clinics, manage-

ment of pharmaceutical supplies, consultation

with mainland medical practitioners, lrorkplace

health and safety duties and co-ordination of all

health requirements for their resort. Clinics are

generally run as ‘cost recovery’ centres, with \Tari-

ous fees charged for customers using health ser-

vices during clinic opening times and for

out-of-hours work. Nursing staff carry either

radios or pagers to maintain constant contact with

the resort duty manager.

Table 1 shows that there is considerable l-aria-

tion in the type of nursing services offered across

the islands. In some cases, nurses are emplo!-ed

full-time and have no other duties. In others. the

nurse may be required to work in other resolt

activities such as front office, housekeeping. the

laundry or child care. Call out fees are sometimes

paid directI>- to the m7rse for delilmering se77-ices

in the middle of the night: but most often the

resort receives this payment. There are also l-aria-

tions in the costs charged to patients for materials

such as dressings and medications, as well as

separate charges at some resorts for the nurse

consulting ])I- telephone with a mainland medical

practitioner. Hamilton is the only island resort on

the Great Ballier Reef where there is a resident

medical practitioner> allowing patients to recol-er

the cost of sell-ices through Medicare.

As domestic and international tourism

increases in Australia: the Comnion~realth

Department of Tourism anticipates that additional

pressures will be placed on the capacit!- of health

and safety services to meet the needs of visitors.‘”

Overseas studies show that up to ;8% of short-

term travellers to the tropics or to Europe report

some health impairment.l3 While most of these

self-reported health problems are not severe

(2143% felt ill; but only 5% needed medical

attention, and less than 1% required admission to

hospital), the current lack of information on med-

ical conditions and injuries experienced by

tourists visiting Australia remains a major obsta-

cle for effective health services planning.739

Kurses, especially those employed at tourist des-

tinations, are an important go”p in protecting the

health of travellers.

Given the possible range of services that

might be required in a remote location, health

care providers need to he aware of the types of

problems that can occur in tourist settings so that

injuries may be prevented and medical conditions

treated effectively. Wilks and Atherton have

recently proposed a frame\\-ork for a national

research program on tourist health.” One of the

key elements in this program is a focus on health

services provided for travellers outside the hospi-

tal setting, especially health needs at the holiday

destination.

In gathering information about primary health

services for ambulatory patients several intelna-

tional classification systems are apmailable. This

study used the International Classification of Pri-

mary Care (ICPC), since it has previously been

applied and validated in a T-ariet!- of clinical set-

tings.‘-‘, Other classifications similar to the ICPC,

such as the International Classification of Health

Problems in Primary Care (ICHPPC-P), have

been used I,>- Lialr to deTmelop patient profiles for

casualt>- presentations at a small rural hospitall”

and for a mral general practice.16 -1pplication of

the ICPC in settings such as island resort clinics

prox’ides an oppoi-t~7nit!~ to test the classification

sl-slem T\-ith a unique set of primal?- health pre-

sentations ant1 to compare remote health care ser-

I~ices across geographical settings.

In tliij stud!-. it was predicted that most of the

health problems ezperieiiced b!- tourists visiting

tropical island resorts would be of an acute

nature. Injuries were expected to be similar to

those experienced I~!~ beach T-isitors in Victoria,

especialI\- lacerations, sprains and strains, sun-

burn and insect bites.17 Medical conditions were

expected to be similar to those reported by pas-

sengers on cruise ships, specificallv presentations

182 AUSTRALIAN JOURNAL OF RURAL HEALTH

for respiratory, musculoskeletal and gastro-

intestinal ailments.l*

It was also predicted that resident nurses

would be able to quickly and effectively treat

these problems, allowing guests to continue to

enjoy their vacation. Patient load was expected be

highest during the main holiday periods, and

lower in the shoulder season. Specialist nursing

services were expected to be required for most of

the presentations, followed by other nursing roles

(such as dispensing medication, liaison with

mainland medical practitioners), with only a rela-

tively small proportion of cases requiring simple

first aid that could have been provided by non-

nursing staff.

mation (names, adclresses) be recorded. Nurses

transferred summary information from their clinic

diaries to a study diary, noting the number of

patients seen each day and the reason for the

visit. Where there was sufficient information

available, a recording form was also completed

for each patient.

METHODS

Study diaries and forms were returned to the

university where they were coded by an experi-

enced health information manager. Medical condi-

tions and injuries were coded according to the

International Classification of Primary Care.l” A

10% random sample of records (r~=118) was blind

coded by a second researcher. Inter-coder reliabil-

ity was 0.90. Any unusual patient cases in the full

sample were then separately identified, cross-

checked and a coding category agreed upon. Data

were analysed using the computer program SPSS-X.

A 6 month retrospective review was made of

records for all guests attending health clinics at

three tropical island resorts off the coast of

Queensland during the period January-June,

1994. At the time of the study, written records

were kept by the clinic nurses in office diaries.

Individual records varied considerably; some

were very detailed, others referring only to the

nature of the service provided.

RESULTS

Reasons for presentation at the island clinics,

based on the primary diagnoses recorded by the

nurses are shown in Figure 1. The main reasons

for presentation were skin problems, ear disor-

ders, respiratory, digestive and musculoskeletal

complaints.

To standardise data collection a recording

form was developed. This form was based on

items used in injury report forms by the Queens-

land Division of Workplace Health and Safety, the

Queensland Injury Surveillance and Prevention

Project, the Queensland University of Technology,

and Standards Australia. The study form sought

details of each medical condition or injury pre-

sented at the clinics, including time of occur-

rence, location, activity at the time and causes of

injury. The form also contained a diagram of a

human figure (front and rear perspectives) to

allow any specific injury sites to be identified.

Details of the treatment provided and basic

demographic characteristics of the patient were

also noted.

The pie chart in Figure 1 was developed using

the ICPC main chapter headings. However, this

broad approach masks most of the detail in the

classification system. Respiratory complaints

accounted for 12.4% of clinic visits, mainly

related to colds/sore throats, chest infections,

Other Gt?neral

5.7%

To protect patient confidentiality, the forms

specifically requested that no identifying infor- FIGURE 1: Presentations to island clinics (n=l183).

REMOTE NURSING AT TOURIST ISLANDS: J. K-1LE;S ET ,4L. 183

FIGURE 2: Breakdown of major reasons for clinic

presentations (5%).

FIGURE 3: Presentations Edith digestive disorders

(n=141).

FIGURE 4: Presentations with other disorders

(n=l62).

upper respiratory tract infections and asthma.

The ‘other’ category here included tonsillitis and

nasal congestion. Figure 2 therefore presents a

breakdown of the major categories for clinical

presentation.

Due to the larger number of specific com-

plaints in the digestive and ‘other disorder’ cate-

400

FIGURE 6: Clinic visits by month.

gories these two groups are presented as separate

figures (Fig. 3 and Fig. 4).

Figure 5 shows the main health services pro-

vided to clinic attenders. The ‘other’ category

consisted mainly of telephone consultations with

a mainland medical practitioner.

A total of 14 patients required medical evacu-

ation to the mainland, and all xere subsequently

admitted to hospital. In terms of patient load, Fig.

6 shop that the greatest number of clinic atten-

dances occurred during January> corresponding to

the post-Christmas holiday period. February is a

quiet month. then there is another increase in

patient numbers during Marcll--April, correspond-

ing to the Easter holiday period. Max- is again rel-

ativeb quiet. xitli numbers beginning to increase

in June for the mid-~-ear school holiday period.

DISCESSION

The present study &oxs that nurses employed at

remote island tourist resorts are called upon to

184 AUSTRALIAN JOURNAL OF RURAL HEALTH

treat a wide variety of health conditions. As pre-

dicted, a majority of the island presentations were

of an acute nature and similar to the most com-

mon reasons for presentation at a small rural hos-

pital. 15 These included lacerations, ear disorders,

sprains and strains, upper respiratory tract infec-

tions and digestive disorders. The range of pre-

sentations was as diverse and challenging as any

that would normally be handled by mainland

medical practitioners. Medical conditions treated

by island nurses were also similar to those

reported for passengers visiting hospitals on

cruise ships in the Caribbean.18 In contrast to the

island cruise ship hospitals are staffed by med-

ical practitioners and have extensive equipment

available for diagnosis and treatment.

In terms of injuries, island clinic presenta-

tions were similar to those reported for beach vis-

itors in Victoria,17 though there were more cases

of bites and stings on the islands, and fewer pre-

sentations for sunburn. Island nurses provided a

range of services for their patients, including

specialist nursing care, assistance with medica-

tion, consultation with mainland medical practi-

tioners, first aid and, in 14 cases, co-ordination of

emergency medical evacuation. Many of these

services are clearly beyond the ability of resort

staff who are trained only in first aid, so there is a

strong argument that all island resorts employ a

resident nurse. In addition, the greatest patient

load occurred during the peak Christmas/new

year holiday season, and there were identified

increases in clinic visits for other corresponding

holiday periods. This has important implications

for health services planning by the resorts to

ensure that adequate numbers of nursing staff are

available during anticipated busy periods.

As noted by Thornton, a nurse working as the

sole health/medical representative in an isolated

community must be self-reliant and competent, a

good communicator with all types of people, sen-

sitive to individual needs, as well as having a

sound clinical background and an awareness of a

variety of health conditi0ns.J

Future studies need to examine in more detail

the role of nurses in remote tourist locations,

especiahy their operation of primary care clinics

as cost recovery centres, management of pharma-

ceuticals and dangerous drugs, patient coun-

selling and their specific contribution to customer

relations. Anecdotal evidence suggests that

nurses play an important role by ensuring that

guests who have become sick or injured in the

course of their vacation receive appropriate care

and therefore do not have their vacation disrupted

by health problems. This has critical financial

consequences for the resorts in terms of repeat

business and favourable word-of-mouth referrals.

As noted in the marketing literature, a customer

with a negative service experience will relate

their story to, on average, 11 other people.19

Island nurses are clearly in a position to rectify

potentially unpleasant guest experiences and are

therefore legitimate members of the tourism

industry. However, it will take time for industry

management to fully accept and appreciate the

important role of the nurse in customer service.

While use of the ICPC facilitated comparisons

between the present study data and that of other

primary health care research, the classification

system was generally found to be limited in sev-

eral ways. First, the system was too broad and

general in its coverage. The main categories, such

as the skin grouping, masked distinctions

between injuries and medical conditions. Second,

there is no mechanism in the classification

scheme to determine the cause of injuries. In this

area the external cause codes available from the

International Classification of Diseases, 9th Revi-

sion, Clinical Modification (ICD-9-CM)“O or the

more recent International Statistical Classifica-

tion of Diseases and Related Health Problems

(ICD-10)2r would be more useful.

These observations on the most appropriate

classification framework for understanding ambu-

latory presentations in remote health care settings

are important if isolated practitioners are to be

assisted in the best ways to record their service

delivery and identify specific education, training

and support needs.

REMOTE UL’RSIKG 1T TOURIST ISLAXDS: J. WLRS ET AL. 185

ACKNOWLEDGEMENTS

This study is part of a series conducted by the

National Reference Centre for Classification in

Health, with funding from the Australian Institute

of Health and Welfare. We would like to thank

John Angel and Lynda Peacock of Australian

Resorts Pty Ltcl for supporting this study and

allowing access to island clinic records. We are

especially grateful to the following clinic nurses

for data collection: Josephine Barnes, Doune

Heppner, Simone Dunn, Deborah Mahony. Kerrie

Paul, Janet Davies and dnne Larkin.

REFERENCES

1 Thornton B. The remote area nurse: Problems of

preparing for the role. Australian Nurses Journal

1991; 21: 10.

2 Buckle!- P. Gray G. Across the Spini&: Registered

i\‘urses W&king in Rural and Remote So11112 .4ris-

tralia. rldelaide: School of Nursing, Flinders Cni-

versity. 1993.

3 Cramer J. Dilemmas of Remote-Area PI-a&w. In

Gary G: Pratt R; eds. Issues in Australian ~\rr.rsi.ng

3. Melbourne: Churchill LiLingstone. 1992.

4 Council of Remote .Irea Xurses of Australia

(CRANA). 6th National Conference: Standds ojf

Remote Area i\;ursing Practice. Sydney-: CR.V-1.

1988.

5 Council of Remote Irea Nurses of iiustralia

(CR-\NII). 7th National Conference: Prinzrrri-

Health Cure in Remote Areas. Alice Springs:

CRANh. 1989.

6 Pasini ‘EX- Tour-ist health as a nex branch of public-

health. World Health Statistics Qzrar-ter!>- 1989:

42: 77-84.

7 Wilks J, Oldenburg B. T ourist health: The siIent

factor in customer service. .-Iustrnliull Jor~rncrl oj”

Hospilalitj- Management 199.5: 2: in press.

8 milks J; Atherton T. Calanaph P. .Id\-enture

tourism brochures: -in anal! sis of legal content.

Australian Jowncd of Hospitcdit~ Idanngernent

1994; 1: 47-53.

9 Wilks J; Atherton T. Health and safet!- in rius-

tralian marine tourism: -1 social. medical and

10

II

12

13

14

15

16

17

18

19

20

21

legal appraisal. Journal of Tourism Studies 1994;

5: Z-16.

Wilks J, Atherton T. Workplace health and safety:

An emerging issue for the Queensland tourism and hospitality industq. .Austru/ian Jozollrnal of

Leisure and Recreation 1994; 4: 37-41.

Atherton T. Package holidays: Tourist’s trial buy

or deal becomes operator’s trial by ordeal. Current

Commercial Law 1993; 1: 100-108.

Commonwealth Department of Tourism. Tourism

- .-lustraliaS Passport to Growth: A tVutiona1

Tourism Strategy. Canbexa: Commonwealth

Department of Tourism. 1992.

Steffen R. Travel medicine: Prevention based on

epidemiological data. Transactions of the Royal

Societ?. of Tropical Medicine and Hygiene 1991;

85: 156-162.

Lamberts H, Wood M, eds. ICPC: Internntional

Classz&ztion of Primary Care. Oxford: Oxford

University Press, 1987.

Liar ST. Casualty encomlters at a small rural hos-

pital. Australian Family Physician 1992; 2 1:

469-474.

Liaw ST. The diagnostic profile of a South Aus-

tralian rural practice. ,kstrnlian Famil?- Physi-

tiara 1991; 20: 1X-183.

Grenfell RD, Ross KN. Hoxr dangerous is that

visit to the beach? A pilot study of beach injuries.

Australian Farnil]. Phyician 1992; 2 1:

114~5-1148.

DiGiovanna T, Rosen T, Forsett R. SiIvertson K, Kelen GD. Shipboard medicine: -4 ne\\- niche for emergency medicine. .41znals of Emergenq. Medi-

cine 1992: 21: 1476-1479.

Horowitz J. Jurgens-Panak >*I. Total Customer Sat-

kfaction: Lessons -from 50 Companies with Top

Qualit!- Cust0me.r Serrice. London: Pitman Pub-

lishing. 1992.

National Coding Centre. iluskdian T’ersion -

Internationa! Classification of Diseases, 9th Reui-

sion: C!inical Mocl~$crrtiorl. Sy-dnex-: National Cod-

ing Centre. 199.5.

‘C;brld Health Organization. ICD-10: Interndonal

Stntisticd Class~f~cution of Diseases und Related

Heulth Problems, Tenth Recision. Geneva: World

Health Organization. 1992.