Rural Nurse, the Consummate Generalist

Nursing and midwifery: Pillars of rural and remote health innovation and development.

Globally, nearly 50% of the population live in rural areas, while just 36% of nurses serve in these locations. Rural nurses face distinct challenges such as limited resources and geographical isolation, and often work with an expanded scope of practice that includes mental health and substance use (MHSU) care. The extent to which rural nurses engage in MHSU care, care barriers, and facilitators has not been previously well described. Thus, this scoping review explored the international research on rural MHSU nursing. The aim was to synthesize the rural MHSU nursing evidence and consider it in relation to Knowing the Rural Community: A Framework for Nursing Practice in Rural and Remote Canada. The research question for this review was, 'What is known about rural nursing related to mental health and/or substance use considerations?' A scoping review approach was used to guide a systematic exploration of the literature. CINAHL, Medline, and PsycINFO databases were searched for international qualitative, quantitative, and mixed-methods scholarly articles with rural MHSU nursing considerations, with no date limiters. Extracted data were mapped to the framework's categories: rural people, community, rural context, and larger society. Forty-seven articles were selected for this critical review of the literature, with most of the articles from Australia (n=15), the US (n=8), Canada (n=7), and South Africa (n=5), and representing rural nurses who worked in hospital (n=16), primary care (n=11), community mental health (n=7), and emergency department (n=6) practice settings. Rural MHSU nursing was described as a generalist and multifaceted role, with challenges such as workplace violence, practice setting and community isolation, and resource inadequacies. Results also indicated that rural MHSU nursing is influenced by a nurse's preparedness for their role, with a lack of preparedness complicated by multilayered resource deficits. Social determinants of health, mental health stigma, and health inequities also affected rural MHSU nursing practice. Despite facing significant barriers, rural nurses demonstrated resilience and commitment to providing quality MHSU care for their communities. Overall, there was congruence between the included studies and the framework. The framework provided a comprehensive foundation for this scoping review. However, based on the findings of this scoping review, minor amendments to the framework are recommended, such as including the rural nurse as an explicit part of the framework. Further, a rural-centric approach that is local, context-sensitive, and developed in collaboration with rural people, was identified as crucial for addressing the unique challenges faced by rural MHSU nurses and their communities. Future rural research should address nursing shortages, practice support, and under-researched areas such as child and youth MHSU nursing and Indigenous health. This scoping review highlighted some of the challenges rural MHSU nurses encounter and provided valuable insights into the complexities of rural MHSU nursing internationally. By using the framework to organize and synthesize the literature, this study contributed to a deeper understanding of the role of rural nurses in addressing MHSU challenges and the context in which rural MHSU nursing care may be situated.

The Last Frontier: Rural Emergency Nurses’ Perceptions of End-of-Life Care Obstacles

The lack of rural nursing studies makes it impossible to know whether rural and urban nurses perceive personal and organizational factors of job satisfaction similarly. Few reports of rural nurse job satisfaction are available. Since the unprecedented shortage of qualified rural nurses requires a greater understanding of what factors are important to retention, studies are needed. An analysis of the literature indicates job satisfaction is studied as both an independent and dependent variable. In this study, the concept is used to examine the intention to remain employed by measuring individual and organizational characteristics; thus, job satisfaction is used as a dependent variable. One hundred and three rural hospital nurses, from hospitals throughout the Northwest region of the United States were recruited for the study. Only nurses employed for more than one year were accepted. The sample completed surveys online. The McCloskey/Mueller Satisfaction Scale, the Gerber Control Over Practice Scale, and two open-ended job satisfaction questions were completed. The qualitative analysis of the open-ended questions identified themes which were then used to support the quantitative findings. Overall alphas were 0.89 for the McCloskey/Mueller Scale and 0.96 for the Gerber Control Over Practice Scale. Rural nurses indicate a preference for rural lifestyles and the incorporation of rural values in organizational practices. Nurses preferred the generalist role with its job variability, and patient variety. Most participants intended to remain employed. The majority of nurses planning to leave employment were unmarried, without children at home, and stated no preference for a rural lifestyle. The least overall satisfied nurses in the sample were employed from 1 to 3 years. Several new findings inform the literature while others support previous workforce studies. Data suggest some job satisfaction elements can be altered by addressing organizational characteristics and by hiring nurses with rural connections, experience and preferences. Rural nurses considered lifestyle and personal life issues when choosing a job. Concepts like time away from work, rural lifestyle, recreation opportunities, climate and social activities influenced the intention to stay on the job. Rural nurses with the most job satisfaction preferred rural lifestyles and possessed rural backgrounds. Since the generalist nurse role requires autonomy and task variability, recruiting nurses who prefer these job characteristics might enhance nurse retention. Other findings were tied to rural health and nursing theories. It is unknown why the most dissatisfied nurses had 1-3 years of experience. Similar studies with larger samples are suggested.

Rural nurses typically fill several roles as needed from acute and extended care settings and to the emergency room. The nurse’s role with aggressive curative efforts involves an intense clinical focus; while end-of-life care entails an intense psychosocial focus. Emergency room (ER) nurses commonly experience these two intense foci of care in succession. Purpose: With the limited resources in rural hospitals, it was necessary to explore the rural influence on rural ER nurses transitioning from curative to end-of-life care. The goal was to capture areas of need to best support rural nurses caring for dying patients and their families in the rural communities. Method: A secondary analysis using deductive content analysis incorporated Rural Nursing Theory to identify rural influences with rural ER nurses transitioning from curative to end-of-life care. In a primary study, Grounded Theory was used to explore ER nurses’ personal transitioning when the focus of patient care changes from curative to end-of-life. Registered nurses (N=10; rural n=6, urban n=4) from four hospitals (2 rural and 2 urban) in four different counties in Upstate New York participated in semi-structured interviews. Analysis yielded 29 concepts and producing five categories: preparing caring, immersion, making sense, changing gears, and reflecting. Three sub-processes, focus, feelings, and conflict were identified as common threads with conflict as a moderating factor influencing nurses transitioning from curative to end of life care. Findings: The concepts of distance, resources, and familiarity had the greatest influence on rural ER nurses transitioning from curative to end-of-life care. The strongest characteristic of rural nurses was self-reliance. For this reason, adequate support and resources are essential to care for dying patients and their families in rural communities. Conclusions: Implications for rural ER nursing include strategies to improve staff resources, access to education, and mentoring. Keywords : Rural, End-of-life, Transition, Emergency, Nurse DOI: http://dx.doi.org/10.14574/ojrnhc.v16i2.396

This survey study describes the workplace social support networks of rural hospital nurses in one geographic region of Colorado. This rural sample was compared with data from a sample of urban hospital nurses in Colorado. Social support networks influence nurses' satisfaction and retention. Nursing recruitment and retention is especially critical in rural areas where it takes healthcare facilities 60% longer than urban facilities to fill nursing vacancies. Little is known about rural nurses' social support networks. The Social Network Questionnaire (SNQ) was mailed to all nurses within one rural region of Colorado. Descriptive, correlational and comparative statistics were used to evaluate the structure and function of these nurses' networks. The nurses' networks were predominantly peer-based, but managers provided significant functional supports. The types of support provided by managers depended on the managers' placement in the nurses' networks. Some managers provided only performance feedback, and other managers offered physical assistance and emotional support. Rural nurses expected more guidance from management than did their urban counterparts. This sample of nurses clearly delineated the types of leadership styles most beneficial to them. Communication of roles and expectations between staff and management can enhance nursing satisfaction in the workplace setting.

Rural nurses’ self-rated knowledge and skills in pain, medication, symptom and emergency management in community-based palliative care: A cross-sectional survey

It has become very evident that the issues, struggles, and stories of rural nurses are similar around the world. As the official journal of the Rural Nurse Organization, this Journal presents these rural nurses’ efforts to our readers in hope of providing a forum for rural nurses to share their stories, both from practice and research, as a way to build the body of knowledge that is rural nursing. During this month in Taipei, Taiwan, the International Counsel of Nursing (ICN) will meet and for the first time the agenda will include a program for the new International Council of Nurses Rural and Remote Nurses Network. This network developed through the work of rural nurses from around the world that began discussions of a need for such a network at the 2nd International Congress of Rural Nurses held in Toowoomba, Queensland, Australia, in 2000. The discussions and development culminated in the incorporation of the group as a network within ICN. This network will provide a global forum for rural nurses and rural nursing science, issues, and practice. The network can be accessed through the ICN website at http://www.icn.ch It is my hope that between the formal organizations for rural nurses and the forum provided by the Journal that the voice of rural nurses will grow strong.

Rural perinatal nursing in Canada: A hermeneutic literature review.

A higher proportion of chronic mental illness is reported for populations residing in inner and outer regional (IOR) areas when compared to major cities in Australia. Conversely, fewer mental health professionals work in IOR areas when compared to major cities indicating poorer access to services for rural populations. Rural emergency departments (EDs) and urgent care centres (UCCs) deliver a broad range of services. Often they are the first point of care for consumers experiencing acute mental health issues. Rural nurses working in EDs and UCCs require a diverse clinical skill set to manage complex presentations, often with limited support and resources. Developments in telehealth services have reportedly improved access for rural consumers. It is known that nurses report a lack of skills and confidence when managing mental health presentations. Despite these challenges, there is little documented regarding the experience of generalist nurses managing acute mental health presentations in rural hospitals that have limited support of community mental health teams and no onsite inpatient mental health facilities. A qualitative study was conducted to explore the experience of rural nurses in managing acute mental health presentations within an emergency context. An interview guide developed from the literature was used to explore issues of experience, safety, knowledge and clinical confidence. Thirteen rural generalist nurses from one rural emergency department and two rural UCCs located in south-west Victoria participated in a semi-structured interview. Interviews were audio-recorded and transcribed verbatim. Transcriptions were thematically analysed by applying an inductive descriptive approach. The majority of participants were experienced generalist registered nurses with no formal qualifications in mental health. Two participants had some clinical experience in mental health and drug and alcohol. Themes elicited from data analysis and discussion between the researchers were (1) 'we are the frontline', (2) 'doing our best to provide care', (3) 'complexities of navigating the system', and (4) 'thinking about change'. Findings indicated that rural generalist nurses deliver the majority of care to mental health consumers in EDs and UCCs. Local mental health clinicians and emergency service providers offer limited support, with a reliance on telephone triage for after-hours assessment. Multiple challenges were cited including coordinating the transfer of consumers to inpatient facilities and feeling inadequately supported. Irrespective of these challenges, nurses reported delivering the best possible care to consumers despite reporting a lack of knowledge and skills. Recommendations for improving the delivery of care included increasing access to emergency mental health training and receiving more support from local mental health teams. The need for more rural mental health facilities was also discussed. The findings from this study suggest generalist nurses are the frontline providers of care for mental health consumers in rural EDs and UCCs. Nurses feel ill-equipped for assessing and managing mental health presentations, relying heavily on local mental health teams and telephone triage who provide limited onsite support. The need to support nurses through training and mentoring relationships with community mental health teams is highlighted by this study in conjunction with improving the delivery of mental health services in rural areas.

School nurses play an important role in identifying children with asthma and providing care during school hours. Educational programs designed to improve nurses' asthma knowledge and practices have concentrated on urban settings. The purpose of this investigation was to determine asthma-related practices and educational needs of rural school nurses. A survey about asthma was mailed to school nurses in all counties of the state of Maryland and in Washington, D.C. Responses were compared between rural Maryland counties and counties from the remainder of Maryland and Washington, D.C. The survey addressed attitudes and beliefs, function and roles, medication administration, and educational needs about asthma. We found that rural nurses used peak flow meters less often to assess and monitor asthma, requested fewer referrals for asthma, had fewer interactions with health room assistants, and had reduced access to asthma educational resources. Also, they provided less asthma education in the schools than other school nurses. These results suggest a need for comprehensive asthma educational programs in rural areas that are based on national guidelines, and that address the unique needs of rural school nurses. These programs should also emphasize the need for open communication between rural school nurses, health room assistants, primary care providers, and parents/caregivers.

[Extract] Australian Rural Nurses and Midwives Inc. provides a voice for rural nurses and midwives in the wider nursing world and in government. We believe that rural nursing is a distinct practice specialty, and we strongly advocate for its recognition. ARNM has an established relationship with CRANA. Over the years there has been a great deal of confusion about why there are two organisations that represent, to outsiders from either rural or remote nursing, the same constituency. Recent developments in the Northern Territory have illustrated the role of the remote area nurse more eloquently than writing a dot point list of differences here. Needless to say rural and remote area nurses face different challenges and need individual representation, while acknowledging the common issues they share.

Environmental, socioeconomic, psychological and familial factors in rural communities predispose children to asthma. This is not only the case in the US but also in the UK, New Zealand and other Western countries. Asthma prevalence ranges from 2.2 to 15%. Because children spend at least 6 hours of their day in school, school health personnel must be attentive to, and skilled in managing the needs and issues faced by children with asthma while at school. Rural school nurses or their deputies need to advise children with asthma about avoiding aeroallergens from hay, smoke, dust, grain in silos and animal dander from cattle and sheep. In the case of children with asthma in rural areas, symptoms may be accepted as long as the child can go to school and play. Parents in rural areas may not believe in routine preventive care for asthma as part of public health practice. Rural nurses need to be aware of current asthma guidelines and apply the concepts to prevention. They need to be proactive and engage in primary, secondary and tertiary prevention. Rural school nurses can begin by using existing resources and adapting these resources for use in rural school environments. Worldwide asthma education is fundamental to asthma patient management.

This study examined rural community-based nurses' self-reported knowledge and skills in the provision of psychosocial care to rural residing palliative and end-of-life clients and carers. We further sought to determine correlates of knowledge gaps to inform workforce education and planning. Nurses from a rural area of Victoria, Australia, were invited to complete an electronic questionnaire rating their knowledge against 6 national palliative care standards and 10 screening and assessment tools. A 5-point scale of (1) No experience to (5) Can teach others was used to rate knowledge. Results were classified into three categories: practice gaps, areas of consolidation, and strengths. Descriptive and logistical regression was used to analyze data. A total of 122 of 165 nurses (response rate = 74%) completed the survey. Of these nurses, 87% were Registered Nurses, 43% had ≥10 years' experience in palliative care, and 40% had palliative care training. The majority of practices across the standards and screening and assessment tools were rated as knowledge strengths (N = 55/67, 82%). Gaps and areas of consolidation were in the use of client and carer assessment tools, the care of specific populations such as children, supporting carers with appropriate referrals, resources, and grief, and facilitating the processes of reporting a death to the coroner. Lack of formal training and lower years of experience were found to be associated with practice gaps. Our study found rural nurses were confident in their knowledge and skills in the majority of psychosocial care. As generalist nurses make up the majority of the rural nursing workforce, further research should be undertaken on what educational strategies are needed to support and upskill rural community-based nurses to undertake formal training in palliative care.

Despite the increased understanding of Canadian rural and remote nursing practice in the past two decades, a synthesis of nursing frameworks to guide practice has been missing from the literature. In this article, the process undertaken to develop a nursing practice framework is described. The purpose of the project was to integrate existing rural and remote nursing evidence into a framework to guide rural nursing practice; inform the actions of rural communities, other health professionals, educators, policymakers and regulators; and support the health of Canadian residents who live in rural and remote areas. Two consultants (DE, JK) worked with the Canadian Association for Rural & Remote Nursing (CARRN) Executive to plan and implement a process to develop a rural and remote nursing framework. An external advisory group, representing regulated nurses, and six expert rural nursing researchers were invited to critique project outcomes. A focused international review of the literature was conducted to determine which rural nursing frameworks existed. Electronic database platforms (ProQuest and the Cumulative Index of Allied Health Literature and Medline) were searched, with literature limited to English-only articles. Each article was analyzed to determine relevant key components and elements. The literature review generated 22 full-text articles that were analyzed and synthesized into five main categories: larger society/determinants of health, role of place/the rural or remote context, rural and remote peoples/communities, rural and remote nursing, and health outcomes. A draft document describing the creation of the framework and two different graphic designs of the framework were developed, then sent to the advisory group for critique. All critiques were reviewed and the document was revised as appropriate. The framework design, which used concentric circles to depict relationships between the five identified categories, was selected by a majority of the advisory group reviewers as being representative of their practice and experience. It is envisioned that, by using the framework, practicing nurses can identify the tightly woven interconnections within the rural context affecting the health of their clients. Nursing assessments and practice can then be strengthened from consideration of the framework. Nursing programs with dedicated rural nursing content potentially could incorporate the rural and remote nursing practice framework document into classroom and clinical discussions. Due to resource and time restrictions, Indigenous and Francophone nurses were not part of the framework discussions, nor were community members living in rural or remote Canada. Ongoing critique from relevant rural groups will be beneficial for future input and revisions. CARRN is developing a knowledge mobilization strategy to begin this process.