Rural Nursing

Most American nurses work in urban hospitals, with only 16% working in rural areas.Rural nurses’ work is different than their urban counterparts, and some consider rural nursing a specialty. 2, 3 Rural nursing generally encompasses a greater scope of practice, requiring independence, flexibility, and a strong sense of adventure. 2, 4 Rural nurses are generalists, but they must have at least some specialty knowledge in multiple areas of nursing. 5 They have older, sicker patients, fewer resources, less supporting staff, testing, and treatment options, 6, 7 and yet they generally manage the most patient care in their home community. When necessary, they support and stabilize their patients and get them safely transferred to a higher level of care for more intensive or specialized treatment.

I have spent the last twenty years as a Certified Nurse Midwife and Family Nurse Practitioner working at a 25-bed critical access hospital that is ninety miles away from a medium-sized city with specialty medical services. We live in an isolated area, and in the winter we can be cut off from the outside world due to bad weather. We live in a tourist area – so in the summer our population swells immensely, with an increase in car and boat and jet-ski accidents, falls from cliffs, snake bites, heat strokes, and heart attacks. Our providers and nurses handle everything from childbirth to multisystem trauma. Our nursing staff is fearless.

The Work

Rural nursing is a strain and a joy. There is endless variety. Rural care requires the ability to use multiple skill sets. This challenge is both a positive aspect of the job and a major source of stress. 7 Maintaining competencies in multiple areas of care is a frequent concern of rural nurses.7, 8 My practice includes primary care, pediatric, and midwifery patients. I deliver babies, admit patients to the hospital and nursing home, and I took ED call for years as the primary provider. My nursing staff has to be able to care for all these patients as well.

Rural nurses have limited resources in terms of staffing, support personnel, and equipment.5 The nurse IS the code team, respiratory therapist, or neonatal nurse. Economies of scale keep providers and health care delivery systems from being able to offer what is routine to city dwellers. Specialty services are not available in small communities, and even some basic providers like obstetricians and pediatricians are not available where the population density is too low to support their practices.Rural dwellers have to travel long distances to access specialty care, yet may not have a budget that allows for travel. Our nurses must have the ability to care for these patients.

SEE ALSO: Roles Outside the Hospital

All our staff nurses receive Advanced Cardiac Life Support, Pediatric Advanced Life Support, and Neonatal Resuscitation training. We train regularly and have frequent drills for high risk, low frequency events. Our staff can choose to cross train for the emergency, labor and delivery and surgery departments. We send our nurses to a large hospital to gain experience in specialty areas. Strong information technology skills and the use of telemedicine helps our nursing staff maintain competence and keep up with evidence based practice. 2

The Patients

Rural patients tend to be different than urban dwellers. They define health as the ability to do work; they tend to be more self-reliant and resist accepting help.Rural patients also expect to receive more personalized care from nurses they know. 2 Rural dwellers are older, often sicker, seek care less often, and are more often poor. 6, 7 The lack of community resources can be associated with earlier mortality.6 A few years ago the Harvard School of Public Health declared that 19% of American women actually have decreasing life expectancy and the majority of these women live in rural areas.9

One of the best and worst aspects of rural nursing is the relationship with patients. Rural nurses understand their patients’ cultural context, whom they are related to, and what their backgrounds are like. 2 Often, this leads to greater understanding and ability to tailor nursing care, as when I know a particular patient is not following her diabetic diet because she has no resources except the Food Bank, which carries no fresh vegetables. Longstanding patient relationships provide the opportunity for running dialogs about health maintenance and lifestyle behaviors.

The Community

Positive aspects of being embedded in the community include having a strong sense of place, a more holistic approach, and a great deal of pride in the practice. 8, 10 Some nurses have described being “transformed by their experience” in rural nursing.10 When a good life event occurs, like a birth, the whole extended family comes to the hospital, and we celebrate with them. Even when the diagnosis is dismal or someone dies, the ability to care for our patients and share their sorrow leads to a deep sense of satisfaction. 

Rural nurses are more visible members of their communities, deeply respected, but also lacking anonymity.2, 8 This can be one of the most difficult parts of rural practice. It is frightening and distressing when a colleague, friend, or neighbor is seriously hurt or ill, but we must put on a therapeutic face and continue to function. Maintaining professional or emotional distance is not easy. Sometimes simple life activities like going to the grocery store can be a chore, where community members want to stop and chat or ask advice. Maintaining confidentiality and a non-judgmental attitude can be more difficult, but is absolutely critical. 2

Colleagues

Rural health care personnel have a broader scope of practice and greater role flexibility than those in urban settings. 4 Collaborative practice between providers and nursing staff is critical. 10 We work very closely together, developing a high degree of trust and respect for each other. There is a greater commitment to our colleagues: we know them, and that they would not be calling for help if it wasn’t truly necessary.7 There is a greater sense of camaraderie, both at and outside of work, which minimizes the more traditional hierarchical relationships seen in urban settings. 11

Rural health care as a nurse or nurse practitioner is exciting, interesting, challenging, and fulfilling. Many critical access hospitals and other rural or underserved areas qualify for school loan repayment. This can make all the difference in financing your education. The down side is you will not have many peers and most of your community will be lower income and less educated, sometimes deeply impoverished. It can get lonely, and it can break your heart. Since you know your patients, it is not as easy to compartmentalize your job and put away the hurt at the end of the day. “Civilized” things like decent shopping, theaters, or even a good dinner out can take three or four hours to get to.

However, I can see the Milky Way from my back deck, even though I live right in town. The air is clean. I can walk to work, or have my kayak on the water in ten minutes. Best of all, I know – absolutely – the difference I have made in my patient’s lives, and in the health of my community.

References

1. Health Resources and Services Administration, Bureau of Health Professions, National Center for Health Workforce Analysis. 2013, April . The US Nursing Workforce: Trends in supply and Education. http://bhpr.hrsa.gov/healthworkforce/reports/nursingworkforce/nursingworkforcefullreport.pdf
2. McCoy, C. 2009, March . Professional development in rural nursing: Challenges and opportunities. The Journal of Continuing Education in Nursing, 80 3 , 128-131.
3. Rural Nurse Organization, Our Mission and Vision, www.rno.org. Retrieved February 5, 2015.
4. Bish, M., Kenny, A., Nay, R. 2012 . A scoping review identifying contemporary issues in rural nursing leadership. Journal of Nursing Scholarship, 44:4, 411-417.
5. MacKinnon, K. 2012 . We cannot staff for “what-ifs”: the social organization of rural nurses’ safeguarding work. Nursing Inquiry, 19,259-269.
6. Bushy, A., 2002 . International perspectives on rural nursing: Australia, Canada, USA. Australian Journal Rural Health, 10, 104-111.
7. Hunsberger, M., Baumann, A., Blythe, J., Crea, M. 2009, Winter . Sustaining the rural workforce: Nursing perspectives on worklife challenges. The Journal of Rural Health, 25 1 , 17-25.
8. Williams, M.A. 2012, Fall . Rural professional isolation: An integrative review. Online Journal of Rural Nursing and Health Care, 12 2 , 3-10.
9. Harvard School of Public Health. 2008, April 21 . Life Expectancy Worsening or Stagnating for Large Segments of the U.S. Population. Press Releases. www.hsph.harvard.edu/news/press-releases/2008-releases/life-expectancy-worsening-or-stagnating-for-large-segment-of-the-us-population.html
10. Greiner, D.S., Glick, D.F., Kulbok, P.A., & Mitchell, E.M. 2008 . Rural health nursing research review: Global perspectives. Annual Review of Nursing Research, 26, 261-294.
11. Yonge, O.J., Myrick, F., Ferguson, L., Grundy, Q. 2013 . “You have to rely on everyone and they on you”: Interdependence and the team based rural nursing preceptorship. Online Journal of Rural Nursing and Health Care, 13 1 , 4-25. Retrieved January 29, 2015.

Dawn Lovelace is Regional Clinical Faculty at Frontier Nursing University and a Certified Nurse-Midwife and Family Nurse Practitioner at Coulee Family Medicine, Grand Coulee, Wash.

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