Why nursing in remote communities can be such a rewarding challenge

Four Queen's Nurses working in Scotland provide an insight into their different roles and why they are undaunted by distance and weather

Four Queen's Nurses working in Scotland provide an insight into their different roles and why they are undaunted by distance and weather

Shetland Islands lead school nurse Keri Ratter. Picture: Dave Donaldson/QNIS

A handful of nurses who live and work in some of the most remote and inaccessible places in Scotland have earned the prestigious Queen’s Nurse title.

From islands set far from the mainland to oil rigs, working in such isolated locations challenges nurses’ clinical practice.

All say that flexibility and collaboration with others is vital.

Shetland Islands lead school nurse Keri Ratter was born and brought up on the archipelago (a chain or group of islands), which lies about 170 km from the Scottish mainland.

‘You have the same challenges everyone else does, you just have them in a slightly different way’

Keri Ratter, school nurse

Ms Ratter was one of a number of remotely located nurses nominated by their executive lead for the 2018 Queen’s Nursing Institute Scotland development programme, which took on a 21-strong cohort.

Describing working on the islands, Ms Ratter says: ‘You have the same challenges everyone else does, you just have them in a slightly different way.’

Geography and climate are a constant test for the school nurse team.

Video messaging

There are 29 schools scattered across the islands, ranging from just four pupils to around 900.

‘It would take me a week to travel to every school and back,’ says Ms Ratter. ‘To travel to Foula, a more remote isle, could take me a whole day.’

Because of this the team are starting to use technology that allows video messaging, although face-to-face contact will never be replaced, says Ms Ratter.

Surrounded by seas and forming part of the divide between the Atlantic Ocean to the west and the North Sea to the east, the islands are subject to dramatic, changing weather that can pose huge barriers to any schedule.

Vulnerable children

Ms Ratter was unable to reach one of the islands due to bad weather last year and finally resorted to waylaying the pupils she wanted to see when they were on the mainland for a trip.

‘You need to have that relationship with schools and parents – our school nursing team doesn’t work like a traditional one.’

Ms Ratter works mainly with youth offenders and vulnerable children and families, including those affected by domestic abuse, substance misuse and risk-taking behaviours.

The rest of her team – three band 5 part-time school staff nurses – take on a more traditional school nurse role, including responsibility for vaccinations.

Long treks in the snow to provide care and support

Queen’s Nursing Institute Scotland chief executive Clare Cable writes:

Community-based nurses working in the remote and rural areas of Scotland often face a very different set of challenges to their colleagues in urban areas – from patchy mobile phone coverage to roads blocked by caravans, livestock or snow, or the complexity of being both a neighbour and a nurse in a small community.

The geography means that some community nurses find themselves as the only health professional on an island or as a nurse specialist covering a large region of the country.

Specialist nurses can cut down the need for people to make long journeys to attend outpatient appointments far away. Increasingly, the use of technology enables staff to connect with others, to have real-time consultations with other clinical expert colleagues and to establish professional networks.

There are great benefits to remote working. The landscape and wildlife of Scotland is extraordinary – imagine walking to work accompanied by seals. Yet the challenges should not be underestimated, whether it is IT systems, huge distances on single-track roads or Scotland’s adverse weather, to ensure patients receive the care and support they need.


Best support

‘I describe us here as “specialist generalists”. We get every single problem you get in any city on the mainland, but we don’t have that number of specialist services,’ says Ms Ratter.

For a patient with specific needs, this approach can entail networking with colleagues on the mainland to provide support, and may mean sending someone off the island.

‘We have to make sure young people have the best support that they can have.’

Ms Ratter  believes all children and young people should have access to an equal, fair and positive school nurse service, even on the most remote of islands.

She is seeking to develop a mental health and well-being pathway in which pupils on Shetland can self-refer and be referred to the school nursing team.

This means allocating a named school staff nurse to each school, including those that can only be reached by ferry or plane.

Close to nature

‘I am responsible for ensuring all the staff nurses have sufficient training, mentoring and time to develop their skills so they are able to build supportive relationships with pupils and support the schools with mental health and well-being issues.’

An advantage to island life, Ms Ratter says, is that the smallness of the community means people know who she is, and she is often able to see people who have made progress after receiving her support.

‘In bigger areas you don’t always see that,’ she says, adding that her love of the sea means the location of her work is another bonus.

‘We are so close to nature, it helps to empty your mind,’ she says. ‘I don’t have to go and look for a park – it is on my doorstep.’

Advanced nurse practitioner Cathanna Smith at Tarbert harbour
Picture: Lesley Martin/QNIS

Recruitment challenge

Back on the mainland, advanced nurse practitioner (ANP) Cathanna Smith, who works in the small harbour village of Tarbert in Argyll and Bute, says recruiting can be a challenge.

Ms Smith is based in a general practice that looks after about 1,800 patients and has an active role in supporting patients whose care is best delivered by an ANP.

She does a lot of management of chronic diseases, as well as supportive nursing to help people to stop smoking and manage their weight, and she runs specialist clinics in asthma, diabetes and stroke.

Making a difference

In addition, Ms Smith does triage by phone for people who need to be seen on that day, and she can send patients for X-rays and ultrasound checks, as well as being a non-medical prescriber.

‘GPs find this makes a huge difference, as it leaves them to deal with the more complicated patients, and that is what I would love to be able to champion.’

Ms Smith is frustrated by a lack of understanding about the ANP role and feels training more nurses to that level would help address the GP recruitment crisis.

‘There are not many nurses at my level, but we can’t get GPs, so why not train up other nurses, which would then help the GP crisis?

‘We struggle recruiting GPs and it is a challenge to recruit to a remote area, but I am a well-qualified nurse looking after patients in a very rural setting.’

Watch a video featuring Queen’s Nurse Cathanna Smith below


Tarbert sits on an isthmus linking the peninsula of Kintyre to Knapdale and West Loch Tarbert, and can be hard to reach.

Landslides have closed many roads in recent years and weather can hinder air or boat transport. Ms Smith describes the ambulance service as ‘at breaking point’.

There are small emergency departments at Campbeltown Hospital, which is a slow 60km away, or Mid Argyll Community Hospital, which is 23km away.

It is also 160km from Glasgow, which can be around a two and a half hour drive.

‘If we don’t have an ambulance, we could be waiting two to three hours with really sick patients.’

Close-knit community

Ms Smith says being part of a close-knit community has benefits and downsides.

‘The nice thing is that over the years you become part of the community, you become “their” nurse and they take you on board,’ she says.

‘You get a lot of respect for what you do, and it is just nice to know people find you are good at what you do.’

But it can be hard to go off duty.

Ms Smith says people will yell at her across the Co-op to ask if she has their test results, and patients have been known to phone her at home or contact her on Facebook.

‘I don’t go out socialising here,’ she says. ‘My whole practice went out for a Christmas meal and someone came up and asked me for their blood results.

She laughs. ‘I started cycling so I could go somewhere but patients jump in front of my bike.

‘You have to understand the demographic of working in a rural area. You can’t be offended by them.’

Substance misuse and mental health liaison nurse Coleen Mcleod
Picture: Sandie Maciver/QNIS

Recovery care

Substance misuse and mental health liaison nurse Coleen Mcleod works for NHS Western Isles, providing and enhancing recovery care across the island of Lewis and Harris in the Outer Hebrides.

‘There are a lot of challenges,’ she explains. ‘The main one is the geography of the island and being able to get to the individuals to assess them.

‘A lot of people who are referred to the service have ongoing issues with benefits and financial problems and cannot afford the bus to come into town, so we have to be flexible as a service.’

Ms Mcleod says she will meet clients with financial problems in places they are able to reach, and around working hours for those who work, despite the service being ostensibly 9am-5pm.

‘We are supposed to be a nine-to-five service. We don’t have wraparound services.’

Another challenge is working with clients who can struggle to move on after a period of abstinence.

'Moving on' programme

‘As a small island, we have the added pressure of fewer employment opportunities and clients being unable to have a fresh start.’

Ms Mcleod has a vision for a programme where third-sector agencies, health professionals and employment agencies commit to contributing to a 12-week ‘moving on’ programme.

Being on first-name terms with other clinicians and service providers is essential.

‘With community nursing I find we work a lot closer together with other disciplines to meet people’s needs within a collaborative care plan to move individuals on.

‘You can’t just do a small piece of work and expect someone else to step in and do the rest.’

Oil rig medic responsible for 90 workers

Bob Gardiner. Picture: Lesley Martin/QNIS

Offshore medic and occupational health and safety adviser Bob Gardiner is the sole healthcare professional on a North Sea oil rig.

In his work for oil firm Taqa, Mr Gardiner has responsibility for primary and emergency care for 90 workers on his platform, which is 300km north east of Shetland.

In his career Mr Gardiner has dealt with a wide range of incidents, from cardiac arrests to multiple deaths and a helicopter crash.

Medical assistance is a minimum of two hours away by air, or sometimes days away in bad weather, he says.

‘We are the lone practitioners in a hazardous role. Sitting with someone who has had a heart attack is a huge responsibility – you are it for that person.’

Stephanie Jones-Berry is a health journalist

This article is for subscribers only