Book Review
Sounding The Alarm
Jennifer Cramer
ISBN: 978-192069436-4 2005 266 pages University of Western Australia Press
Sue Lenthal
Senior Lecturer, Centre for Remote Health, Flinders University, Alice Springs NT
Cramer paints a grim picture of nursing in remote areas of Australia. Based on research for a PhD thesis, Jennifer Cramer's book 'Sounding the Alarm' explores the practice of nurses at Warburton, a remote Indigenous community in Western Australia.
Cramer describes the inadequacies in the recruitment of nurses, the nurses' lack of relevant preparation, the overwhelming expectations of communities and employers, the 24 hr on-call and the gulf between normal nursing practice and what was practiced at Warburton. She argues that nurses acted as substitute doctors, describing their decision making as medically orientated and beyond their training and capabilities.
She uses the term amorphous practice to define the changeable character of practice from 'nurse to nurse, from situation to situation and from time to time'. Three subcategories of amorphous practice are termed detachment, diffusion and beyond the nursing domain. Detachment reflects the nurses 'feelings of separation and distance from the organizations and systems usually required for nursing practice', 'diffusion refers to the wide-ranging parameters of remote practice', nurses are expected to be pharmacists, doctors, psychologists and anything else that was needed. The third subcategory beyond the nursing domain describes the unregulated practice that was beyond the boundaries of nursing practice.
Cramer argues that this unregulated practice contributes to poor health outcomes for Indigenous peoples and would not be tolerated by non-Indigenous people.
In some areas Cramer's book seems out of date and ignores much that the profession itself, through the Council of Remote Area Nurses of Australia (CRANA) has developed to set standards and improve practice. Her distinction between nursing and medical practice does not reflect the current thinking of the profession. Remote area nursing is viewed as advanced nursing practice rather than GP substitution.
Cramer's research at Warburton seems to have occurred before 1999 when a post-graduate program developed in partnership by CRANA and Flinders University to prepare nurses to work in remote areas was established. A memorandum of understanding has existed since 2001 with the Ngaanyatjarra Health Service, who run the Warburton clinic, that supports nurses in undertaking the program. There have been other advances in the education of remote area nurses such as a four week orientation program by the Northern Territory Department of Health and Community Service. There have also been advances in the development of stronger standard treatment protocols, with a fourth edition of the Central Australian Remote Practice Axxx (CARPA) standard treatment manual. The picture of remote area nursing now seems a little brighter than when Cramer conducted her research.
However the book does explore important issues that have been too easy for governments, professional bodies and health services to ignore. It is hoped that this book will 'Sound the Alarm' and more emphasis, including support and funding will be given to the delivery of health services in remote Indigenous communities and to the education of remote area nurses for their advanced practice role.
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