Purpose: Adverse childhood experiences (ACEs) and low utilization of mental health services due to distrust of the healthcare system and stigma contribute to poor mental health outcomes, especially for individuals living in rural areas. Evidence mounts that ACEs and mental health conditions contribute to poor sleep, yet ACEs remain understudied in rural southern communities where Black Americans face disproportionate racial and socioeconomic disparities. This study examined whether ACEs and depressive symptoms predict sleep quality in rural Black Americans, identified the types and frequency of ACEs reported among those with depressive symptoms, and explored correlations between sleep quality and ACEs overall and by specific type. Method: Participants (N = 75), Black/African American adults who completed a series of questionnaires, including a demographic survey, Patient Health Questionnaire (PHQ-9), modified ACEs, and answered two questions assessing components of sleep quality, including sleep duration and satisfaction. Findings: Of the 75 participants, 56% (n = 42) reported depressive symptoms. Among those with depressive symptoms, 40.5% (n = 17) reported having parents that had separated or divorced, and 23.8% (n = 10) reported not feeling loved by anyone in the family, and that family did not look out for each other. Sleep duration was shorter for participants who reported living with someone experiencing substance use or mental illness, p < .05. Adverse childhood experiences and depressive symptoms were not associated with sleep quality, all p >.05. Conclusion: Community-focused interventions, specifically trauma-informed care models, are needed to address the potential impact of specific ACEs on mental health outcomes within rural Black Americans.

Purpose: To analyze research studies comparing midwife-led care to physician-led care and to compare state-regulatory frameworks and policies for midwives and women’s healthcare. Sample: Fifteen articles published between 2017 and 2022 presenting data on births in the United States. Method: A keyword search of EBSCOhost, Google Scholar, Wiley Online Library, and PubMed databases. Papers were analyzed if published between 2016-2023, written in English, and studied U.S. populations. A quality appraisal using the John Hopkins Nursing Evidence-Based Practice tool and a synthesis approach similar to Perriman et al. (2018) were used to develop objectives for qualifying articles. Findings: Midwife-led care has lower rates of birthing interventions and increased rates of patient satisfaction than physicians. Conclusions: Midwives are a crucial resource with adequate research displaying their innate ability to care for women and infants in an empowering and respectful birthing environment. The state of Texas must act to scale-up and utilize this resource to increase access to health care and improve women’s health. Research should be continued to identify stakeholder involvement in advocacy for expanding the midwifery scope of practice and to determine reasoning for the lack of data collection and reporting mechanisms within this field. The need to draft and ratify legislation to either equally regulate midwives of all occupations or to remove collaborative/supervisory frameworks is evident.

If you are reading this editorial, you most likely know or want to know about rural nursing.In nursing education, a generalist usually refers to someone who has a nursing undergraduate degree, since they need to be educated about and have some clinical experience in multiple areas.Nursing advanced education usually focuses on various specialty areas.A rural nurse needs excellent generalist skills and knowledge, and their practice is such that they need breadth and depth of knowledge in multiple areas.A good deal of nursing is similar in different practice settings and with various populations (Bushy, 2012).However, it has long been argued that rural populations and their health care needs have unique practice demands.Thus, there are unique aspects of rural nursing (Bushy, 1998; Crook, 2004; Long & Wienert, 1989).Scharff notes, "The nature and scope of rural nursing is distinctive" (2022, p. 87).My perspective has been informed by education, derived from practice in both rural and urban settings, as well as immersion in rural nursing literature.I see rural and urban nursing as a Venn diagram, although my ability to show this is limited.The intersection area is the discipline of nursing, where the knowledge needed is similar.

Purpose: Certified nursing assistants (CNAs) are essential, direct caregivers within the long-term care (LTC) setting. When traumatic events occur within LTC, CNAs are often involved, resulting in potentially negative consequences for the CNA. There has been limited research about rural LTC CNAs, which is a concern due to CNAs’ important role and rural disparities they encounter. The purpose of this study was to explore the experience of CNAs who have faced a traumatic event while working in the rural LTC setting. Sample: Nine CNAs were purposively recruited from two rural LTC facilities in a predominately rural upper Midwest state. Inclusion criteria included being a CNA, having experienced a traumatic event in a LTC workplace setting, speaking English, being at least 18 years old, and working in a rural area as defined by HRSA. Method: This study used an interpretive phenomenological design. Semi-structured interviews occurred via Zoom. Analysis involved an iterative process that included dwelling with the data and the use of a hermeneutic circle. Findings: All participants were white females, which is consistent with the CNA demographics within the area. An overarching theme of The Raging River emerged, along with the five supporting themes of Forward Motion, Nourisher, Drowning, Cold Resources, and Desperation for a Lifeline. Conclusions: The CNAs described complex experiences, demonstrating both their strength to continue forward and their vulnerability and necessity of support. Caring for residents in the rural LTC setting brings unique challenges. This study demonstrated a clear need for future research to provide better support to rural LTC CNAs. DOI: https://doi.org/10.14574/ojrnhc.v25i1.789

Introduction: Clinical cancer screening rates are low among patients who identify as LGBTQ+, especially in rural areas. It is important for rural nurse practitioner (NP) students to be aware of health disparities in cancer screenings among LGBTQ+ and be able to effectively promote cancer screenings in this population. Purpose: The purpose of this project was to determine rural NP students’ knowledge, attitudes, and perceptions of barriers to cancer screenings among LGBTQ+ and to educate NP students on inclusivity related to cancer screenings in this marginalized group. Sample: Nurse practitioner students at a public, rural, liberal arts university Method: Rural NP students participated in an interactive, in-person workshop to which the community was also invited. Didactic information was provided regarding barriers to/awareness of the need for cancer screenings among LGBTQ+ individuals. Students also created educational materials for use in community prevention programming. An anonymized online post-survey assessed NP students’ knowledge, attitudes, perceptions, and awareness of cancer screenings among LGBTQ+. Findings: Over 90% of participants (n=62) reported increased knowledge about the healthcare needs of LGBTQ+ populations. The largest mean level of agreement was observed with the statements, “how knowledgeable are you about the healthcare needs of LGBTQ+ populations?” and “how knowledgeable are you about current terms that should be used to increase inclusivity of LGBTQ+ populations in a healthcare setting?”, both resulting in a mean score of 3.52 corresponding with “very knowledgeable”. Three qualitative themes included recognizing the significance of culturally appropriate communication, having increased awareness of recommendations for cancer screening in the LGBTQ+ population, and the importance of reflecting on internal personal biases. Conclusion: Curricular strategies that promote awareness and increase knowledge of LGBTQ+ patient needs are essential to develop a rural NP workforce that can promote health equity and competently care for all patients.

Purpose: The purpose of this project was to implement the American Diabetes Association (ADA) Diabetes Risk screening tool and measure adherence to the Diabetic Plate patient education protocol in a rural, primary care clinic in North Carolina (NC). Sample: The setting of the project was a small, outpatient, rural primary care clinic in Western NC that serves a town population of 7,492 persons. Those of any age with a BMI > 25 were eligible for screening. During implementation, 334 patients were seen, and 157 met eligibility criteria. Method: The participating healthcare provider and medical assistants administered the ADA screening tool to eligible patients during their visits. If the patient scored a five or higher, indicating high risk for diabetes, the provider would then provide ADA Diabetes Plate education to inform patients of early T2DM prevention techniques. Completed screening tools were collected bi-weekly and charts reviewed to assess provider and staff adherence with screening. Findings: Out of the 157 eligible patients, 89 patients were screened utilizing the diabetes risk assessment tool. Of the patients screened, 41 were deemed “high risk” and 32 of them received diabetes plate education from the provider. The participating provider and clinic were able to screen eligible patients utilizing the diabetes risk screening tool with a 56.69% success rate and 78.04% of high-risk patients received diabetes plate education. Conclusions: Limitations of the project included inconsistent screening and discrepancies between paper screening forms and EHR documentation. Despite limitations, final data suggests that implementation of the ADA diabetes risk assessment tool could be beneficial in rural regions where ease of access and affordability is paramount. Additionally, implementation of this easy-to-use tool within an existing EHR would likely improve staff screening compliance and improve patient follow-up.

Purpose. While stress, anxiety, depression, and professional well-being are beginning to be explored in newly graduated registered nurses as key psychological determinants in their transition to practice, these variables are poorly described in those transitioning to practice in rural settings. Therefore, this study aimed to describe the prevalence of and associations among these variables in newly graduated registered nurses transitioning to practice in rural community and critical access hospitals in Texas. Sample. Using convenience sampling and multiple recruitment methods, 24 registered nurses with a range of 4 to 23 months’ experience participated in the study. Method. A cross-sectional, associational research design was used. After obtaining Institutional Review Board approval, participants completed online surveys regarding their perceptions of stress, anxiety, depression, professional well-being, job satisfaction, and resignation ideation. Findings. Participants reported a mean age of 29.6 years and were mostly female (91.7%) and white (70.8%). High levels of job satisfaction were reported by 62% of the sample and only one-third reported frequent thoughts of resignation ideation. Slightly more than half of the participants (58.4%) reported a lower or at-risk level of professional well-being. Lower levels of professional well-being were significantly associated with higher levels of perceived stress, depression, and anxiety, more frequent resignation ideation, and lower levels of job satisfaction. Conclusions More research is needed to understand the determinants and outcomes of professional well-being in registered nurses transitioning to practice in rural settings to develop evidence-based interventions to help rural nurse preceptors, educators, and leaders to support them. DOI: https://doi.org/10.14574/ojrnhc.v24i2.769

Purpose: Stress-reducing activities have been known to lower turnover and improve employee mood. Animal-assisted therapy (AAT) has been used to help patients through stressful situations; however, little research exists on the impact that AAT has on rural healthcare workers. The purpose of this project was to develop and implement an AAT program at three rural clinics in northern Illinois and assess the program's association with employee mood and burnout. Sample: Sixty-five percent (n=28) employees participated in the study. However, two were lost to attrition. Method: A dog-based AAT intervention was developed and implemented at three rural clinics. During the intervention, all participants were allowed to interact with the therapy dog for an undetermined amount of time over the lunch hour for ten sessions. The intervention was evaluated using a pre/post-test design. Burnout was measured using The Copenhagen Burnout Inventory (CBI) at the beginning and end of the intervention, and mood was assessed using a one-item question before and after each session. Findings: A paired sample t-test was used to assess changes in the three subscales of the CBI from the start to the end of the study and to identify mood changes. There was not a significant change in personal or work-related burnout. However, there was a decrease in client-related burnout from the beginning of the intervention (m=50.78, ±30.17) to the end (m=39.32, ±26.57, p<.001). In addition, average employee mood improved by 49.62% (p</=.004) after each session. Conclusion: This pilot study suggests that implementing AAT within a rural clinic setting might improve healthcare worker (HCW) mood and decrease the risk of client-related burnout. More research is needed to determine the long-term impacts of these programs and their association with HCW well-being.

Purpose: Critical access hospitals (CAHs) play a crucial role in rural healthcare, especially during crises (e.g., the COVID-19 pandemic). This study addresses how changes in swing bed operations from spring to fall of 2020 influenced CAHs by focusing on their operations, staff experiences, and community engagement. Sample: Fourteen staff from five CAHs in the US participated in this study. Method: Descriptive, qualitative research design with semi-structured interviews. Findings: During the first year of the COVID-19 pandemic, CAHs faced challenges in maintaining swing bed operations due to resource constraints and increased patient volumes, leading to changes in swing bed operation. The findings highlight four team approaches adopted by CAHs during the changes in swing bed operations: (1) implementing innovative patient care strategies, (2) providing support, (3) strengthening community bonds, and (4) empowering community education. Staff developed innovative patient care strategies (e.g., using baby monitors) due to insufficient standardized protocols, equipment, and in-house care for severe cases. Telehealth became a critical tool to maintain patient care amidst staff shortages and patient reluctance to visit clinical settings. Community support, including local residents and retired healthcare professionals, played a crucial role in meeting the demands. Upper management highlighted cross-training, financial incentives, and role adjustments to address staffing shortages and enhance team unity. CAHs actively engaged in community education and support through various platforms to provide information on COVID-19, testing, and vaccinations. Conclusions: Collaboration among CAH staff and strong community support facilitated effective resource management and a return to pre-pandemic operational levels. This study underscores the importance of CAHs in rural healthcare during crises and highlights the need for continued support and investment in these essential healthcare providers to ensure they can sustain operations and effectively respond to future health emergencies. DOI: https://doi.org/10.14574/ojrnhc.v24i2.777

Purpose: This study explores the experiences of prelicensure nursing students participating in a community-engaged learning (CEL) activity designed to enhance their understanding of social determinants of health (SDOH) and their impact on residents in a southern rural community. Sample: The sample consisted of junior-level baccalaureate nursing students enrolled in a "Health Assessment for Professional Nursing" course across three semesters in 2023, with a total participant pool of 286 students. Method: A qualitative approach was employed, guided by Moustaka’s phenomenological framework. Data were collected through reflective journaling, with 352 responses received from 61.5% of the sample population. From these, 40% (n=140) were randomly selected for data analysis. Thematic analysis was conducted using open coding, categorization, and identification of core and peripheral themes. Trustworthiness was ensured through member checking and peer review. Findings: The analysis revealed three main themes: “Interacting with Others:” Participants appreciated the personal stories shared by residents, which fostered empathy and a deeper understanding of aging and community life. “Strategies for Sparking Conversations and Relating to Residents:” Students adapted their communication styles to connect with residents, recognizing the importance of patience and empathy. “Challenging Stereotypes and Biases:” Participants confronted and reshaped their biases through meaningful interactions, highlighting the importance of respect and dignity in healthcare practice. Conclusion: Participation in the CEL activity significantly enhanced students' understanding of SDOH, fostering empathy and awareness that can translate into improved care for rural residents. The study underscores the importance of experiential learning in nursing education to prepare students for the complexities of real-world healthcare environments. However, the findings are specific to this context and may not be broadly applicable. Future research should include community member perspectives and explore broader applicability. DOI: https://doi.org/10.14574/ojrnhc.v24i2.773