Getting value for money in remote areas

Some time ago, I wrote about using Bush Orders to do grocery shopping.  This is how we avoid being ripped off by price-gouging remote area stores, as we pay normal supermarket prices for our groceries in a regional centre, then pay freight to get it to our home.  This compares very favourably with prices in our local supermarket, and vastly improves the range and quality of goods we can access.

In general, I support the concept "buy local".  I'm even prepared to pay a premium to support a local store.  However, I am not prepared to support businesses who use a captive market to price-gouge, and often provide abysmal customer service as well.  It seems I am not alone in this.  A recent survey reported in CHOICE magazine found that NT has the highest per capita use of online shopping in Australia, and that's despite a significant portion of the NT population having little or no access to online services.  No longer can NT businesses sit back and treat their customers with contempt while charging them a large premium for goods.  We will simply order them online, and when this proves to be a positive experience, as it almost always does, we are unlikely ever to go back to the local business.

In my case, I can choose whether to buy a part for my 4WD locally and pay 2 1/2 times more for it, or order it online and wait a week for it to arrive.  In rare cases, I'll pay the extra because I can't wait, but mostly (about 98% of the time) I will take the online option.  If the local business kept their mark-up to even 50% compared to city prices, I would but it from them every time.  But a 150% mark-up is stupid!  Especially when their customer service is surly, unhelpful and often downright hostile.  Even for basic food items that I can't do without, I will wait a week to get them via freight from Alice Springs than buy them locally, mainly because the local supermarket charges between 200-400% more for many items.  Sure some items are as cheap as elesewhere, but they tend to be the junk food lines rather than the healthy foods.  Fruit and vegetables here are expensive and highly variable in quality, sometimes barely edible.  Yet the same items bought via Bush Orders from Woolworths in Alice Springs are fresh, excellent quality, and usually less than half the price even allowing for freight.

It's not all doom and gloom though.  I recently bought a tyre for the Transit van.  After days of searching online, I found 3 tyres that would do the job.  All were around $240, with between $30 and $100 freight to get the tyre to Tennant Creek.  I then went to the local tyre outlet to check what they had.  The pleasant helpful person on the front desk checked the computer and found the size I needed in a well-known brand for $250 including fitting and balancing, and it was in stock!  So here's one business that managed to get it right:

• Good customer service
• Competitive price
• Quality goods

So guess where my first stop for all my future tyre needs in Tennant Creek will be?  Yep, the local tyre outlet.  They could have charged another $100 for the tyre, and probably got away with it once, but this would have meant that all future tyres would be bought either online or while on a trip elsewhere.  By giving me value for money, they have ensured that I will support this particular local business.  And that's probably worth more to them in the long run than a quick $100 once-off.

Report on CRANAplus Conference 2011

Well, I guess it's about time that I posted something about the 2011 conference in Perth.  It was held on October 11-14 and I think it was the best one yet.  As CRANAplus has grown, the conference organising has more and more become a staff responsibility, with a subsequent improvement in the quality and feel of the conference.  The next step may be to use a conference organiser, but we'll see how things go with the current setup.

The conference kicked off on the Tuesday evening with a cocktail event, a combination of opening ceremony and presentation of the inaugural Fellows of CRANAplus, as well as the annual presentation of graduates from relevant postgraduate courses in remote health.  I was privileged to become a CRANAplus Fellow, as well as being recognised for my recently acquired Master of Remote Health Practice - Nurse Practitioner qualification.  So it was two walks to the podium for me!

On Wednesday morning, the conference proper got under way with a keynote address from Professor Colleen Hayward and a smorgamsbord of interersting and informative talks from presenters around Australia.  This continued until lunch time on the Friday, with some very special treats on the way.  A presenter from the Solomon Islands shared some of his work in the Solomon Islands Red Cross, and a group of Rural Health Club students amazed us with their passion for remote health.  The catering along the way was superb, and facilitated many opportunities to chat with colleagues.  One of the highlights of the CRANAplus conferences is the chance to catch us with old friends, and make new ones.  This time was no exception, as I saw people who I hadn't caught up with since last year's conference, and added a lot of new people to my list of contacts.

My own presentation entitled "Dealing with uncertainty in remote and isolated practice" was on Friday morning, and was well received. I have been asked by a number of people if they could use it in presentations of their own, and also if I could present it in other settings in the NT.  No worries, I'm happy to share what I've learned, and if it helps others, so much the better!

Next year, the 30th CRANAplus Conference will be held in Cairns, and I can hardly wait. 

Distance Education

Most of my education has been by one form or other of distance education.  My first 2 years of schooling were Grade 1 and Grade 2 at Meadows Primary School, then just as I was starting Grade 3, we moved out bush.  Our farm was 20km from the nearest bus stop, and the school was a 1 1/4 hour bus ride from that bus stop.  Rather than spend such a huge chunk of time sitting on a bus each school day, I was introduced to the South Australian Correspondence School (now SA Open Access College) and began my lifelong love affair with distance learning.  Every fortnight I would receive a package from the Correspondence School, which I would complete in 2 or 3 days then have the rest of the fortnight off.  Compared to the boredom and lack of intellectual stimulation of the classroom environment, it was Utopia!  It wasn't until Year 11 that I had to spend more than a week to complete each fortnight's package, and my grade sheets showed A's across the board.

I left school at the end of Year 11 to start work as a farm labourer, shearer, grain handler, truck driver, and fence fixer.  The plan was to get together enough resources to acquire my own land and become a farmer.  I was given the opportunity to do some cereal sharefarming in the mid 1980's which was to be my foot in the door.  Unfortunately both crops I was involved in financing failed, and I saw the writing on the wall.  Now what to do?  I decided to go back to school and complete Year 12, then go to university.  Year 12 was a culture shock, as I was 21 in a crowd of 17-year-olds, and had not set foot in a classroom since early 1974.  However, my independent study skills learned from the Correspondence School helped me to do well and complete Year 12 with a 96% grade.

Then came four years at university trying to find out what I wanted to do.  A year of Electronic and Electrical Engineering, a year of Mechanical Engineering, and two years of Surveying left me still confused what I was going to do.  During all of this, I was a volunteer Ambulance Officer, and in my second year of Surveying I starting going out with the daughter of a GP.  I spend many hours with this GP (and the daughter of course!!) discussing health care etc, and she suggested I should try medicine as a career.  So I applied, but was knocked back as a bad risk due to three uncompleted degrees already.  The Dean of the School of Medicine at Adelaide University suggested I acquire a nursing degree, then if I achieved high grades he would give me a place in medical school.

Three years later I graduated with a Bachelor of Nursing with the highest grade point average of my class over the three years.  Much of what I learned during my nursing degree was self-directed as I quickly found the lectures and tutorials were pitched at the lowest common denominator and were unbelievably boring.  So I spent much of the three years teaching myself from textbooks and journal articles, just like I used to do with the Correspondence School.  It worked for me, as I achieved a high enough grade (High Distinction average) to go to medical school.  Unfortunately for entering medical school, but fortunately for my life in general, I married Anita shortly after graduation and decided to stick with nursing for the time being as I was sick of being a penniless student.

My next educational endeavour was two years later when I was working is a busy metropolitan ED, and began a graduate program for Emergency Nursing.  This was almost entirely by distance education, and left me with a graduate certificate in Emergency Nursing.

Then after yet another change in my career, I ended up working as a Remote Area Nurse in Oodnadatta SA.  It didn't take me long to realise that I knew almost nothing that I needed to know to be effective, so it was back to distance education to fill the gaps.  I enrolled in the Master of Remote Health Practice and completed it over 3 years, then the Master of Remote Health Management over two more years.  The possibility of becoming a Remote Nurse Practitioner became achievable in 2010, so I then completed a bridging course to convert my first Masters to a Master of Remote Health (Nurse Practitioner).

What's next?  Well right now I'm refreshing my ALS certification via an online unit with CRANAplus, and in the next few months it is possible that I'll have the opportunity to start a PhD program.  So the love affair with learning, and in particular distance education, continues.  I am thrilled that my children have had the opportunity to do some of their schooling via Alice Springs School of the Air, as it has exposed them to the self-discipline, challenges and rewards of distance education.  If the skills they acquire through this form of learning are as useful to their lives as they have been in mine, then they will be fortunate indeed.

Making a difference

One of the things that makes work worthwhile is the opportunity to make a difference.  In my experience, this is a factor which is often underestimated, or perhaps undervalued, by managers.  It goes part of the way to explain why throwing money at remote health jobs does little to resolve the chronic shortage of personnel.  In fact, in some ways throwing increased money at remote staff has the effect of attracting mercenaries who are only 'in it for the money'.

So if it's not the money, and let's face it, the salary package for a Remote Area Nurse is among the best you can get in the profession, then what is it that keeps people in the field?  Well, my opinion is based on my experience as a Remote Area Nurse, as a remote Health Centre Manager, and as a manager of volunteers.  I think it depends to a large extent on the ability to make a difference, and to see and feel that you are doing so.  For many nurses, life is one of boredom and drudgery, doing the same work over and over again in a never-ending cycle until their backs pack up or they burn out physically and emotionally.  For a few, the rewards that come from helping a patient to find the road to health and follow it make up for all the failures.  It's all very well to patronise struggling nurses and tell them to 'focus on the successes and let the rest slide by'.  Unfortunately that ignores the reality of human nature, where we feel deeply our failures and they erode our confidence underneath the veneer of professional cheerfulness.  Making a difference to people is what makes the difference to us.  This is true of many endeavours, but I think it is most relevant when caring is part of the job description.

During my time in the SA Country Fire Service, I came to realise that most volunteers were giving their time and energy to the organisation because they could make a difference, and that met a need within themselves for their lives to mean something.  This was true even, or perhaps especially, of those who professed to believe religious dogma which was supposed to meet this need.  I used to think it was about the need to belong, and maybe in some ways that's a frequent starting point.  Now I think it is more about making a difference, and being recognised for doing so, that keeps people doing things that others find amazing.  Whether it is fighting fires in your own time, or living and working in a remote community away from family and friends, it is the opportunity to make a difference, and the recognition for doing so that is a potent driver for people sticking with it.

What this means for remote health is that if managers want to be serious about attracting and retaining good staff in the field, they need to stop their senseless bickering and bitchiness about little things that don't make a difference.  They need to focus on making it possible for staff to make a difference.  In Aboriginal communities, this means making a real effort, not the usual token gesture, to include Aboriginal Health Workers as part of the team.  Remote Area Nurses are hampered in their drive to make a difference if they don't have the tools and support they need, and a big part of this is the Aboriginal Health Workers.  Any RAN who doesn't see this needs to do themselves a favour and get the hell out of Aboriginal health ASAP.

To stop the soul-destroying revolving door of acute health care, the health system needs to be reformed to put more money into prevention than it does into cure.  Most of the work in remote Health Centres is acute care arising from preventable causes, yet bugger all is spent on prevention.  Managers tend to express their awareness of this stupidity by blaming the Remote Area Nurses for neglecting prevention, when it is the almost total lack of support and funding for prevention activities that stops it from happening.  You can't make a difference when the cards are stacked against you, and when your own employer is doing the stacking and then blaming you for it, it is not long before no amount of money will compensate for the disillusionment.

So what's the solution?  Give remote health professionals the tools they nned and the support they need to do what most of them are there for, to make a difference.  If you can't do that, or don't know how, then do everyone a favour and get out of remote health and give the job to someone who can.  Either that, or stop pretending that we are in the business of Primary Health Care and rename the health centres "Remote Band-Aid Stations".  Then we can keep wasting time and money and dedicated staff for another 50 years!

Bush Orders - bringing competition to remote areas

One of my long-held beliefs is that people who live in rural and remote areas need to support their local businesses, or risk losing them.  After all, city-based people are not going to drive to the middle of nowhere for the privilege of paying higher prices for a restricted range of lower quality goods.  So if those of us who live outside the cities don't pay up, country businesses will go belly-up.  I'm OK with that, because as far as I'm concerned, the country life is worth the extra expense, especially when you often get to save money in other ways so it balances out.

However, there is a limit.  In Tennant Creek, the sole local supermarket has a captive market which they shamelessly milk for all it's worth.  A regular fortnight's shopping at Tennant Creek will cost me at least $800, and that leaves quite a few items that I can't get at all until I go shopping in Alice Springs.  A comparable shopping trolley full in Alice Springs costs around $500, and includes everything I need.  The quality of fruit and vegetables is highly variable, ranging from OK to inedible, and staples like milk powder and bread are nearly twice the price that they are in Alice Springs.  There have apparently been a number of attempts to start up a bakery in Tennant Creek, but each time the supermarket conducts a price war until the bakery goes broke.  Then the price of bread goes through the roof again.

This is where Bush Orders comes in.  I am a Woolworths customer, so can only talk about their service, but I know Coles do it as well.  Every fortnight I fax a list of what I need to Woolworths in Alice Springs.  The Bush Orders team do the shopping for me, for a $20 fee (which is being scrapped soon) and pack it into boxes.  Meat and bakery items are frozen, fruit and dairy goods chilled, and the rest packed as general goods.  Most times it takes 6 boxes to pack my order (2 frozen, 2 chilled and 2 general).  I then pay $6 per box to have them freighted to Tennant Creek where they are held at the freight depot for me to collect at my convenience.  I could get them delivered to my door, but since I work nights, it's better if I collect them myself.  Then when I get home, it's like Christmas!  Everyone is keen to see what came in the boxes.  I'm caught up in it too, even though I placed the order, because the Bush Orders team usually throw in some freebies as well.

So for me, the benefits of Bush Orders are:

• Avoiding the extortion of a monopoly business
• Ordering groceries eliminates impulse shopping, as all purchases are planned
• I can still buy specials, by referring to the specials catalogue online that applies to Alice Springs
• It saves me having to drive to Alice Springs to buy the items that are not available in Tennant Creek
• I save the cost of the $20 shopping fee just in the bread, and more than recoup the $48 freight on everything else. On top of that, I save over $200 by not having to drive to Alice Springs.

Disadvantages are:

• It is hard to explore new items that we might like to try, so this has to wait until we travel to a Woolworths store. I can browse Woolworths online, but not the Alice Springs store.
• I have to keep money available in my account for up to 3 weeks as it seems to take that long for Woolworths to deduct the payment.  If I change to using a credit card for these purchases, that will eliminate this delay.
• We end up with a mountain of boxes that need to be disposed of.
• I like impulse shopping!!  Not that it's good for me.

Overall then, Bush Orders allows us to enjoy the services, range and quality available from a major regional supermarket for a relatively minor fee.  While I would like to support local business, I cannot support extortion.  I understand that businesses need to make a profit, but they need to understand that we live in a global economy and if they can't compete, they're out.  If that means no local supermarket, so be it.  The reality of course is that there will always be a supermarket here, and if a second one opens, competition will bring prices down to a fair level.  The supermarket pay their staff a pittance and don't open long hours, and freight is very competitive, so that doesn't justify the high prices.  Therefore I refuse to accept them.  Long live Bush Orders!!

Leadership

To pass the time on night shift, I was having a discussion with a colleague about various things affecting the nursing profession.  We covered a lot of things, and one of them was leadership.  It is sometimes (or often?) said that nursing suffers from a lack of leadership.  What does that mean?  What is leadership anyway?

In 2009-2010 I had the great privilege of participating in Course 16 of the Australian Rural Leadership Program, so I may have some answers. Or not.

Leadership is about moving forward, taking a group of people towards a shared goal.  It involves inspiration, encouragement, and negotiation.  It requires integrity and commitment, and a healthy dose of self-awareness and self-criticism for the leader.  An effective leader is one who is able to see both the day-to-day realities that impact on outcomes, but also the big picture that shows what it's all about and where we are heading.  He or she needs to be able to communicate the vision, and inspire other people to strive towards achieving it.

If this sounds like a tall order, that's good.  It is a tall order, and the reality is that if we settle for anything less from our leaders, we are shortchanging ourselves.  Leadership is not meant to be easy, although there are some very inspirational leaders who make it look easy.  Don't be fooled by appearances - it is very likely that these people work extremely hard behind the scenes to make things work up front.

So does nursing lack leadership?  I guess that depends on what standards you set, and which branch of the nursing tree you focus on.  The whole organism has some excellent leaders, such as the Commonwealth Chief Nurse (Rosemary Bryant), but the same cannot be said for all of the specialties.  For example, remote health relies on a few dedicated individuals to raise the standards and push for meaningful reform, but the general tone is one of mediocrity and pettiness.  The peak professional body CRANAplus can and does provide some of the leadership required at the big-picture level, but what is often sorely lacking is grass-roots leaders.  People are needed who are willing to step up to the plate and make their own practice exemplary, then accept the challenge to be role models to their peers.  'Tall poppy syndrome' is very real, but leaders have to rise above such petty jealousies and show the way to improve the world around them.  After all, if you can't make a difference by being a good leader, or by following one, what's the point?