Rural Health Care Settings Research Articles

Development and validation of a novel approach to work sampling: a study of nurse practitioner work patterns

Objectives: This methodological paper reports on the development and validation of a work sampling instrument and data collection processes to conduct a national study of nurse practitioners’ work patterns. Design: Published work sampling instruments provided the basis for development and validation of a tool for use in a national study of nurse practitioner work activities across diverse contextual and clinical service models. Steps taken in the approach included design of a nurse practitioner‑specific data collection tool and development of an innovative web‑based program to train and establish inter rater reliability of a team of data collectors who were geographically dispersed across metropolitan, rural and remote health care settings. Setting: The study is part of a large funded study into nurse practitioner service. The Australian Nurse Practitioner Study is a national study phased over three years and was designed to provide essential information for Australian health service planners, regulators and consumer groups on the profile, process and outcome of nurse practitioner service. Results: The outcome if this phase of the study is empirically tested instruments, process and training materials for use in an international context by investigators interested in conducting a national study of nurse practitioner work practices. Conclusion: Development and preparation of a new approach to describing nurse practitioner practices using work sampling methods provides the groundwork for international collaboration in evaluation of nurse practitioner service.

Rural Indonesian health care workers' constructs of infection prevention and control knowledge

Understanding the constructs of knowledge behind clinical practices in low-resource rural health care settings with limited laboratory facilities and surveillance programs may help in designing resource-appropriate infection prevention and control education. Multiple qualitative methods of direct observations, individual and group focus discussions, and document analysis were used to examine health care workers' knowledge of infection prevention and control practices in intravenous therapy, antibiotic therapy, instrument reprocessing, and hand hygiene in 10 rural Indonesian health care facilities. Awareness of health care-associated infections was low. Protocols were in the main based on verbal instructions handed down through the ranks of health care workers. The evidence-based knowledge gained across professional training was overridden by empiricism, nonscientific modifications, and organizational and societal cultures when resources were restricted or patients demanded inappropriate therapies. This phenomenon remained undetected by accreditation systems and clinical educators. Rural Indonesian health care workers would benefit from a formal introduction to evidence-based practice that would deconstruct individual protocols that include nonscientific knowledge. To achieve levels of acceptable patient safety, protocols would have to be both evidence-based and resource-appropriate.

An Integrated Approach to Methicillin-ResistantStaphylococcus aureusControl in a Rural, Regional-Referral Healthcare Setting

To curtail the prevalence and cross-transmission of methicillin-resistant Staphylococcus aureus (MRSA) in a rural healthcare setting. Before-after, quasi-experimental quality improvement study. A regional-referral hospital, 5 affiliated nursing homes, and an outpatient MRSA clinic. Residents of the 5 nursing homes were screened for MRSA at baseline and 1 year later. Active surveillance cultures were performed on subsequently admitted nursing home residents, "high-risk" patients admitted to the hospital, and household contacts of clinic patients. The decolonization regimen consisted of systemic therapy with minocycline and rifampin and topical therapy with nasal mupirocin ointment and 5% tea tree oil body wash. Three separate samples for cultures to document clearance of MRSA colonization were obtained at 1-week intervals 1 month after the completion of decolonization therapy. Samples for follow-up cultures were obtained at month 6 and month 12 after the completion of decolonization therapy. After intervention and follow-up for 12 months or more, the prevalence of MRSA carriage at the nursing homes decreased by 67% (P < .001), and 120 (82%) of 147 nursing home residents and 111 (89%) of 125 clinic patients remained culture-negative for MRSA. Twenty-three (24%) of 95 new clinic patients had at least 1 MRSA-positive contact. Mupirocin resistance did not develop. In the hospital, the incidence rate of nosocomial MRSA infection decreased from 0.64 infections per 1,000 patient-days before the interventions to 0.40 infections per 1,000 patient-days 1 year after the interventions and to 0.32 infections per 1,000 patient-days 2 years after the intervention (P < .01). Use of active surveillance cultures and decolonization therapy was effective in decreasing the prevalence of asymptomatic carriage, the incidence of nosocomial infection, and the overall prevalence of MRSA in our rural healthcare setting.

Exploration of interaction and shared care arrangements of generalist community nurses and external nursing teams in a rural health setting

Objective: The purpose of this pilot study was to determine the understanding of nurses within a shared care model and the degree of interaction evident in their practice in the shared care nursing environment in a rural caresetting. Sharing of care between different nursing teams can allow for the improved use of minimal resources available in rural communities. The objectives of the research were firstly, to identify the interactions of nursing teams in a shared care model and secondly, to determine how shared care is evident in their practice. The final objective was to draw attention to the importance of shared care models in rural health settings and to develop recommendationsto support shared care models. Design: A qualitative, non experimental, grounded theory descriptive study was used in this research. Setting: Primary care. Subjects: The sample comprised the generalist community health team, which consisted of registered nurses with more than 5 years post registration experience in community health nursing and two external nursing teams, comprised of a palliative care team and an aged care team. Main Outcome Measures: Identification of the nursing interactions and shared care practices in order to develop recommendations to foster and support shared care models in changing health structures. Results: The study generated four themes: a lack of understanding of each teams’ roles; difficulties in communication of information; the importance of setting shared goals in care planning; and the need for collaboration to ensure clarity in case coordination. Conclusion: Results suggest that confusion around role, skills, communication, care planning and coordination of care within a shared care model are creating barriers to effective sharing of care. Co‑location of services should enhance sharing of care. These results should facilitate the development of care approaches that maximise health outcomes and contribute to a better understanding of collaborative processes that can assist in the provision of health care in rural settings.

Evaluation of the Effectiveness of a Transcutaneous Bilirubin Measuring Device in a Rural Health Care Setting

Evaluation of the Effectiveness of a Transcutaneous Bilirubin Measuring Device in a Rural Health Care Setting

Experiences of nurses working in a rural primary health-care setting in Mopani district, Limpopo Province

Professional nurses working in rural primary health-care settings are experiencing burnout due to serious shortages of personnel. This is exacerbated by the brain drain of nurses leaving the country. Rural settings are resource constrained in terms of personnel and equipment. This results in dissatisfaction among nurses due to the unbearable working conditions which result in stress and frustration. A qualitative, explorative, descriptive study was conducted to explore and describe the experiences of nurses working in a rural primary health-care setting in the greater Letaba sub-district in Limpopo Province. Purposive sampling was used to identify the participants. Data was collected in the form of in-depth interviews. The study revealed that nurses working in primary health-care settings were experiencing emotional and physical strain as a result of the shortage of human resources. It was recommended that policies that meet the health-care needs of rural communities be developed, and that strategies to retain professional nurses in primary health-care settings be formulated.

Trends in Rural and Urban Deliveries and Vaginal Births: California 1998‐2002

Pregnant women in rural areas may give birth in either rural or urban hospitals. Differences in outcomes between rural and urban hospitals may influence patient decision making. Trends in rural and urban obstetric deliveries and neonatal and maternal mortality in California were compared to inform policy development and patient and provider decision making in rural health care settings. Deliveries in California hospitals identified by the California Department of Health Services, Birth Statistical Master Files for years 1998 through 2002 were analyzed. Three groups of interest were created: rural hospital births to all mothers, urban hospital births to rural mothers, and urban hospital births to urban mothers. Of 2,620,096 births analyzed, less than 4% were at rural hospitals. Neonatal death rates were significantly higher in babies born to rural mothers with no pregnancy complications who delivered a normal weight baby vaginally at an urban hospital compared to urban mothers delivering at an urban hospital (0.2 [CI 0.2-0.4] deaths per 1,000 births versus 0.1 [CI 0.1-0.1]). Logistic regression analysis showed that delivery in a rural hospital was a protective factor compared to urban mothers delivering in an urban hospital, with an odds ratio of 0.8 (CI 0.6-0.9). Maternal death rates were not different. Rural obstetric services in this period showed favorable neonatal and maternal safety profiles. This information should reassure patients considering a rural hospital delivery, and aid policy makers and health care providers striving to ensure access to obstetric services for rural populations.

Urban and Rural Health Care Environments: Factors Affecting New Graduates' Choice for Employment

Rural and urban health care settings in Canada vary in terms of patient population and available medical services. For the health professional, this variety of health care settings and range of work environments has a direct effect on job satisfaction. To ensure professional fulfillment, a new graduate should consider several factors when selecting employment.

Research on Rural Veterans: An Analysis of the Literature

The Veterans Health Administration (VA) provides comprehensive health care services to veterans across the United States. Recently, the VA established an Office of Rural Health to address the health care needs of rural veterans. To review the literature on rural veterans' health care needs in order to identify areas for future research. We conducted a literature review of articles listed in the Medline, CINAHL, and BIOSIS datasets since 1950. We reviewed and summarized the findings of 50 articles that specifically examined rural veterans. The literature on rural veterans included 4 articles examining access to care, 7 evaluating distance technology, 4 examining new models of care delivery, 11 studying rural veterans' patient characteristics, 10 evaluating programs provided in a rural setting, 6 examining rural health care settings, and 8 exploring rural veterans' health services utilization patterns. Most studies were small, based on data obtained before 2000, and consisted of uncontrolled, retrospective, descriptive studies of health care provided in rural VA settings. Definitions of rural were inconsistent, and in 20% of the articles examined the rural aspect of the setting was incidental to the study. The literature on rural veterans' health care needs warrants expansion and investment so that policy makers can make informed decisions in an environment of limited resources and competing interests.

Nursing Patient Safety Research in Rural Health Care Settings

Adverse events occur in virtually all health care arenas, and while rural health care settings are no exception, these facilities often face unique financial burdens and personnel shortages. That may hamper patient safety efforts. Many of the interventions recommended to improve patient safety have largely been based on research conducted in urban hospitals. This chapter demonstrates the extent and type of nursing research being conducted to advance rural-specific patient safety research. The studies were conducted in various settings, with topics ranging from error reporting in hospitals to safety screening in the community. Limitations of these works are discussed, and the chapter offers guidance for a future nursing research agenda to include the need for interdisciplinary research; cross-national and international collaboration; and, at a minimum, the necessity for nurse researchers to sample rural hospitals in larger studies of patient safety.

Substance Abuse Treatment Provider Views of “Culture”: Implications for Behavioral Health Care in Rural Settings

Mandates for culturally competent substance abuse and mental health services call for behavioral health providers to recognize and engage cultural issues. These efforts to incorporate culture typically focus on client culture, but provider views of culture can also influence the provision of services. Analysis of 42 semistructured interviews with behavioral health providers suggests that culture is considered by many to be an obstacle to help seeking and treatment of substance-abusing youth. Although some providers do not highlight cultural issues, others conceptualize culture in terms of (a) generalized Hispanic cultural attributes, (b) male-dominant gender roles, and (c) the culture of poverty. Recommendations for provider training on cultural issues focus on ways they might critically consider their ideas about culture.

Sustainability of the workforce: Government policies and the rural fit

Critical workforce issues among health care workers have raised public concerns about the ability of health care systems to provide adequate service. Services, however, are influenced by geographical and social factors. One important source of variation is rurality. This study evaluated the perception of the applicability of health human resource policies for rural areas. An exploratory design was used. Twenty-one nurse administrators and 44 staff nurses from a sampling of 19 rural health care settings were interviewed. Hospitals with less than 100 beds were targeted. The government policies most frequently mentioned by study participants were the goal of 70% full-time employment, the new graduate policy and the late career initiative. Each presented challenges to managers attempting implementation. Urban bias is apparent in health care policy including health human resource policies. Little data is available about rural health care workers because health care statistics tend to be reported regionally. Rural institutions have difficulty accessing government funding intended to build sustainable workforces. Policies meant to be broadly implemented across jurisdictions may not fit the needs of rural institutions and their clients. Health care databases should include a rural variable to enhance understanding about this population.

Improving Work Environment Perceptions for Nurses Employed in a Rural Setting

Effective recruitment and retention of professional nurses is a survival strategy for health care facilities, especially in rural areas. This study examines the use of the Individual Workload Perception Scale to measure nurse satisfaction by a small rural hospital in order to make positive changes in the work environment for nurses. Baseline work environment perceptions of nurses employed in a rural Kentucky hospital were assessed using the Individual Workload Perception Scale, a validated 38-item instrument. Nurses reviewed the results and brainstormed on potential interventions to address areas of concern. The 4 interventions selected for implementation by the nursing staff included (1) implementation of a shared decision making or governance model; (2) enhanced role of licensed practical nurses within the organization; (3) augmentation of administrative support on night and weekend shifts; and (4) utilization of wireless communication devices. After implementation of the interventions, staff nurse perceptions were reassessed using the same tool. The follow-up survey revealed improvements in all areas measured by the Individual Workload Perception Scale, with the greatest improvement in the perception of the work environment noted among night nurses. The increase in positive work environment perception among these nurses, with greater than or equal to 11 years of professional experience, was statistically significant. Tools exist to support the development and evaluation of interventions to improve the work environment for nurses practicing in rural health care settings. By addressing issues of specific concern, both job satisfaction and retention of this talented pool of professionals can be enhanced.

Entrepreneurial IT Governance

Governance is traditionally viewed as a formal authority structure. Information Technology (IT) governance parallels this in that it refers to the patterns of authority over IT. However, traditional control theories of governance, particularly those applied to IT, may not apply in rural healthcare settings. Healthcare has significantly underinvested in IT. Even today, the vast majority of healthcare transactions occur via telephone, fax, paper, and EDI; much data is not captured, is captured incorrectly or inefficiently, and is difficult to retrieve and use. Employing an established IT governance framework, and working from the fundamental assumption that IT is a vital tool in the capture and use of healthcare data, the authors explore the appropriateness of the traditional IT governance framework within a rural healthcare setting. We present an innovative, non authoritative, relationship-oriented approach for those seeking successful adoption of IT as a means of improving healthcare in rural settings.

Evaluation of the WHO Haemoglobin Colour Scale for diagnosis of anaemia in children and pregnant women as used by primary health care nurses and community health workers in western Kenya

To evaluate the diagnostic accuracy of the WHO Haemoglobin Colour Scale (HCS) for anaemia in three groups of children aged 2 months to 2 years (sick children, those visiting an immunization clinic and a community-based random sample of children) and a sample of pregnant women. Finger-prick blood samples were taken from all consenting participants. Haemoglobin (Hb) levels from the HCS were compared with results from a HemoCue portable haemoglobinometer. Sensitivity, specificity and positive and negative predictive values for the HCS were calculated. A total of 457 sick children, 336 children visiting immunization clinics, 454 children from the community at large and 643 pregnant women participated. The prevalence of anaemia (Hb<11 g/dl) in these groups was 87%, 79%, 74% and 52%, respectively. The prevalence of severe anaemia (Hb<7 g/dl) was 24%, 11%, 10% and 2%, respectively. The sensitivity of the HCS for anaemia ranged from 60% to 79% and specificity from 59% to 94%. The sensitivity of the HCS for severe anaemia ranged from 24% to 63% and the specificity from 97% to 100%. Through use of the HCS, the proportion of sick, anaemic children visiting peripheral health facilities diagnosed and treated for anaemia would increase from 3% to 65%. In an area with high prevalence of anaemia among sick children, use of the HCS has the potential to significantly increase the proportion of sick, anaemic children who are diagnosed with anaemia and given appropriate treatment. Further evaluations of the effect of the use of the HCS on treatment practices at the health facility level are required.

Interview with a Quality Leader: Ira Moscovice on Quality in Rural Healthcare Settings

1Sue Boisvert, MHSA RN, is vice president of quality at St. Andrews Hospital and Healthcare Center in Boothbay Harbor, ME. She is a member of JHQ's review panel.

Oral misoprostol for prevention of postpartum hemorrhage by paramedical workers in India

Objective To study whether paramedical workers from rural primary health centers in India are able to administer oral misoprostol and actively manage the third stage of labor to prevent postpartum hemorrhage (PPH). Method Cluster randomization was used to enroll 1200 women at 30 peripheral health centers from 5 states in India, 600 forming the study's intervention group (active management of the third stage of labor with 600 μg of oral misoprostol) and 600 forming the comparison group (in which the current government guidelines for the prevention of PPH were followed). The primary outcome was blood loss after delivery, which was measured using a calibrated blood collection drape. Results Age, literacy level, occupation, and gravidity were similar in the 2 groups. More than 70% of women in both groups had moderate anemia (hemoglobin level < 10 g/dL). Paramedical workers followed instructions in almost all deliveries in the intervention group (99%). There was a significant reduction in duration of the third stage of labor (7.9 ± 4.2 min vs. 10.9 ± 4.3 min; p < .001) and median blood loss after delivery (100 mL vs. 200 mL; p < .001) in the intervention group. Overall, a low incidence of PPH was observed (< 1%) in both groups. A greater number of women had moderate to severe shivering (12.7% vs. 0.5%) and a temperature higher than 38 °C (9.7% vs. 4.3%) in the intervention group, which was statistically significant. Conclusion Simple interventions can be easily implemented in rural health care settings to reduce the blood loss during labor. This finding has significant implications for developing countries, in which the prevalence of anemia is high.

Development of a common national questionnaire to evaluate student perceptions about the Australian Rural Clinical Schools Program

The Australian Commonwealth Department of Health and Ageing provided funds for the Australian medical schools to establish Rural Clinical Schools. This workforce initiative has enabled medical students to learn in a diverse range of rural and remote healthcare settings. A common questionnaire was developed and agreed on by all the directors of the Rural Clinical Schools. Use of this common questionnaire will facilitate reports on student attitudes and program outcomes, both within individual Rural Clinical Schools and at a national program level. The data analysis will inform the community and the Australian Government about the effectiveness of the national Rural Clinical School program in (1) meeting the primary aims of providing high quality rural medical education; and (2) addressing the medical workforce shortage in rural and remote areas.

Methicillin-resistantStaphylococcus aureusand Vancomycin-resistant Enterococci in Rural Communities, Western United States

The impact and prevalence of antimicrobial drug resistance in rural community healthcare settings is uncertain. Prospective surveillance in 51 rural hospitals in Idaho and Utah examined the epidemiologic features of clinical cases of methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant enterococci (VRE). Thirty-two cases of VRE were reported; for 6, the patient had no prior healthcare exposure or coexisting condition. Among the 724 MRSA cases available for evaluation, 405 (56%) were healthcare-associated (HA-MRSA), and 319 (44%) were community-associated (CA-MRSA). The characteristics of HA-MRSA and CA-MRSA patients with coexisting factors were similar, which suggests community transmission of healthcare strains. CA-MRSA cases without coexisting factors, however, demonstrated features previously reported for community strains. MRSA infections were substantially more frequent than VRE in rural communities in the western United States. Based on epidemiologic criteria, a large proportion of MRSA cases were community-associated. CA-MRSA rates were predictive of institutional MRSA rates.

Burnout—a personal journey

SummaryIn this personal reflection on burnout, the context of work and its related stress is explored, particularly in a rural public health care setting. However, beyond the work-related challenges, the wider experience of stress in a person's life and developmental crises contribute to the capacity to cope with the demands of working in a resource-poor setting. The process of recovering from burnout is a slow journey that needs time and space in order to overcome the chronic exhaustion, the cynicism and the lack of meaning.