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Running head: RURAL NURSING: ISSUE ANALYSIS 1

Rural Nursing: Issue Analysis

Amber Paige Gall

Ferris State University

RURAL NURSING: ISSUE ANALYSIS 2

Abstract

Rural nursing is a recently newly examined topic, but a rapidly growing field. All too

often this field has been overlooked and ignored. This paper will examine the need for

nurses in the rural field and how largely affected by rural nursing a patient can be. We

will also examine the skills and knowledge a rural nurse must possess in order to care for

her patients effectively. The need for more research and education in this field will also

be thoroughly discussed.


Rural Nursing: Issue Analysis

Twenty percent of our nation’s population resides in rural areas. This population

needs and deserves to have proper access to healthcare. They also deserve to have the

same quality of healthcare that their urban counterparts receive at large urban facilities.

The nurses serving this population also need to have the same knowledge, skills, and

abilities as urban nurses have in their specialty. So what needs to occur for this to

happen? The rural population is often underserved, uninsured, unemployed, and

overlooked. Little research has been done on this population leaving a gap in both the

healthcare these patients receive and their access options. Rural hospitals are smaller,

have less resources, and less specialties. The rural nurse must be a generalist; meaning

he/she must possess the skill set and knowledge base to be ready for anything on a given

day.

Rural nursing has only begun to be looked at as a specialty and this field has long

been overlooked even though these nurses care for a large portion of the population.

Much more research is needed to develop the specialty of rural nursing and strengthen the

body of knowledge surrounding this topic (Williams, Andrews, Zanni, & Fahs, n.d.).

This specialty of nursing is overlooked from day one of nursing school. There are few

textbooks, lectures, and even fewer clinicals focused on this area leaving students with

little insight into how rewarding a nursing career in this field can be. Nursing graduates

are much more likely to take their first job in a specialty or unit they have been on and

already have some experience with. Where the problem arises is that rural areas are

smaller, meaning they do not possess as many resources and teaching abilities as urban

hospitals for nursing students. Educating, hiring, and retaining nurses in these smaller


areas where there is often less money as well is especially difficult as well (Molinari,

Monserud, & Hudzinski, 2008).

When the word “rural” is thought of many people immediately imagine a picture

perfect setting with farmhouses and rolling hills, but not many think about the nursing

care needed in this area (McCoy, 2009). Often there is one hospital serving a large

population of rural residents. This translates into long travel times and little options for

access to healthcare. The United States Census (2010) defines an urban area as having an

urban nucleus of 50,000 or more individuals and having a population density of 1,000

individuals per square mile. This means all other areas are considered rural. According

to the United States Census (2010) 80.7% of the population resides in urban areas and

19.3% reside in rural areas as of 2010. To give some solid numbers this means the

number of people in the United States living in rural areas is around 51 million. This is a

substantial number.

The rural nurse faces many challenges throughout her career and shift on a daily

basis. “Rural dwellers define health as primarily the ability to work, to be productive,

and to do usual tasks” (McCoy, 2008, p.128). Residents of this population are more

likely to ignore suggestions given by primary care providers and other medical personnel

if they are able to go about their daily life uninterrupted. Often serious conditions such as

diabetes mellitus, and congestive health failure are ignored until the symptoms interfere

with daily living. Rural nursing involves a large amount of crisis management and

recovery because these patients have ignored the interventions required to prevent the

serious adverse effects to their disease processes. Rural residents are also more self-

sufficient, more resistant to accept any help from others, and rural health care providers


are very much engulfed in their community than those serving in the urban community

(McCoy, 2008). Patients of the rural nurse are likely to be a friend, relative, or co-worker

because of the small town in which surrounds the hospital. This can be viewed as a

negative or benefit to many.

Rural Nursing and Theory

Although little concentration has been placed on rural nursing, the biggest

advance has come from Kathleen A. Long and Clarann Weinert who have created the

rural nursing theory. The development of this theory was created based on the fact that

rural dwellers cannot benefit from most current nursing models and special

considerations need to be made when caring for this population. Weinert and Long

originally created their theory base in 1989. Recently Weinert (2009) published an article

in Reflections of Nursing Leadership; here she discusses that not much progress or

advance has been made over the last ten years. Rural nursing continues to face

challenges such as the specific needs of rural dwellers, lack of rural nursing based

research, and small sample sized studies. However, there is also some good news to

share about rural nursing that include a nursing journal dedicating to rural nursing

(Online Journal of Rural Nursing) and a doctoral program dedicated to rural nursing at

Binghamton University (Weinert, 2009). These advances are a must have when it comes

to expanding the knowledge base of rural nursing theory.

Another theorist whose concepts can be related to rural nursing is Dorothea Orem.

Orem first published this theory in 1971. One of the main themes of this theory is that

nursing is a helping service and the goal of nursing is to help the patient with the self care

deficits so they may regain a normal or near normal state of health (“Dorothea Orem’s


Self Care Theory”, 2012). No matter what specialty of nursing you are looking at the

ultimate goal as stated in Orem’s theory is to help the patient regain their health so they

may once again function (2012). Orem’s theory is further broken down into a few major

concepts. She explains the requisites of the self care theory as maintenance of sufficient

intake of air, water, food, provision of care associated with elimination processes, balance

between activity and rest, prevention of hazards to human life well being, and promotion

of human functioning (2012). Rural nursing can apply the concepts of this theory as

well. The difficulty arises with this in two ways. The first being that patients present to

rural healthcare facilities with higher acuity than those in urban areas and secondly rural

nurses do not have access to as many resources as nurses practicing in urban areas.

Nurses in rural areas are expected and pressured to develop a wide scope of practice

because they may be one of the few health professionals accessible to the rural resident,

this becomes extremely difficult when rural nurses are faced with such challenges such as

isolation, lack of development opportunities, higher patient acuities, and insufficient

recruitment (Bish, Kenny, & Nay, 2012).

The difficulty with all nursing theories in this area is that little attention has been

given to the area of rural nursing. Orem’s theory can help guide rural nurses in caring for

patients, but again they must implement these interventions without the resources of their

urban counterparts. Once one chooses to practice in the field of rural nursing he/she is

also faced with professional isolation, which only further complicates incorporating any

theory into care (Williams, n.d.). Research and continuing education in nursing theory is

mandatory in order to bring about improved care, knowledge, and attention to the

specialty of rural nursing. Both the patients and nurses in rural communities face too


many disadvantages that could be prevented and/or corrected with more research. The

knowledge base has increased surrounding rural nursing, but not enough.

Challenges faced by Rural Nurses

The World Health Organization (WHO) states, “The health system consists of all

organizations, people and actions whose primary interest is to promote, restore or

maintain health. This can be analysed in its totality by using different groups or six key

building blocks”(WRPO, 2013). These blocks are health services, health workforce,

health information, essential medicines, health financing system, and leadership or

governance. The goal of all of these key building blocks is to deliver safe, effective, and

quality care. However rural nurses and patients do not always have access to all of these

building blocks causing a gap in the care they both give and receive.

The first and foremost challenge that rural nurses face is the ability to safely carry

out care for their patients with limited resources. Unlike their urban counterparts rural

nurses work in smaller facilities for less pay with less resources, less staffing, care for

higher acuity patients, and are required to know a broad base of disease processes. Rural

patients admit that they avoid recommendations given by primary care physicians

because of financial restraints so when a rural patient does finally come to a rural

healthcare facility they present with more advanced and higher acuity disease processes

such as uncontrolled hypertension or diabetes. And all too often it seems that the patient

is having a massive complication of their disease process such as an acute myocardial

infarction or stroke. The skills needed by a nurse working in a forty-bed hospital differ

from those of a nurse working in an urban level 1 trauma center hospital. The rural nurse

must be a generalist meaning that he/she must posses a wide array of knowledge of


disease processes and how to mange them when caring for patients. During one shift a

nurse may have to manage many more problems than his/her urban counterpart including

head trauma, CHF, geriatrics, pediatrics, obstetrics, and psychiatrics. In these situations

the rural nurse must perform crisis management, and effectively use the resources

available to him/her to effectively care for patients leaving a gap in multiple building

blocks of this framework.

Having a healthy workforce is imperative to allowing nurses to give the best care

possible to their patients and the best chance for positive outcomes. Lets look at the

example of rural emergency departments. For a large majority of rural patients their only

means of access to healthcare is through the emergency department due to lack of

primary care physicians or insurance. All of these circumstances lead to the

overcrowding of rural emergency departments. These hospitals have less staff, less

financial security, fewer medical providers, and less diversity of medications. This

leaves a lot of room for a patient to fall through the cracks of the health system. Rural

emergency departments also have a larger population of elderly people with more chronic

illnesses complicating the medical attention they require even further (Van Vonderen,

2008). Also there are geographical barriers such as large unpopulated areas,

communication challenges, and provision of services over physical barriers as well

(Whitney et al., 2010). The job of the rural emergency nurse and their coworkers is

often to quickly stabilize a patient and then arrange transport and admission to a higher

acuity hospital that is better equipped to care for the patient’s needs. In order for a

system like this to function efficiently there needs to be cohesion and cooperation

between the rural hospital, EMS, and the surrounding higher acuity facilities. All the


care given pre hospital by EMS, during the hospital visit, and during transport to another

facility has an effect on the patient’s outcome.

Hospitals in rural areas lack the financial stability that urban medical centers

have and many have had to close their doors, leaving even fewer hospitals to treat this

population. Patients in emergency situations often have to wait longer due to longer

response times needed by emergency medical services (EMS) and longer transport times

to higher acuity facilities. Time is a constant enemy to the rural nurse and patient

(Whitney et al, 2010). This further emphasizes the need to have knowledgeable nurses in

this environment; they must be ready for any situation that comes their way from a toe

laceration to a cardiac arrest.

Implications and Consequences

What does all of this mean for the rural nurse? All of these issues point to two

major consequences. The rural nurse faces an uphill battle everyday and so does the rural

patient. Although rural nurses may see fewer trauma or critically ill patients and have

less opportunity to practice their skills in these types of situations they need to be

prepared for any situation to arise (Whitney et al., 2010). Rural hospitals are missing

some key building blocks and are therefore running less efficiently and have a higher risk

of having patient quality and safety issues. The education and knowledge regarding rural

nursing needs to be brought into the present and examined thoroughly by schools,

researchers, and theorists. More attention needs to be placed on recruitment and retention

of nurses in rural hospitals, as failure to do so in rural settings is a major problem in the

United States (Williams, n.d.). Once hired into a system rural nurses need to be given

educational opportunities like their urban counterparts so that professional isolation does


not become a concern, as this has been a huge barrier to recruitment and retention in this

area (Williams, n.d.). The issue has been recognized as a problem and with advances in

technology as well as more urban hospitals forming partnerships with rural outlying

facilities more opportunities are becoming available to the rural nurse. It is vital in the

rural healthcare system to having both strong nurses and strong nursing leadership

because of the complexity and diversity of issues that have to be dealt with on a daily

basis (Bish, Kenny, & Nay, 2012).

Issues such as overcrowding in rural hospitals are not going to disappear anytime

soon. Rural hospitals lack the financial support and back up to implement new strategies

that are reasonable solutions for urban hospitals. All the more reason the rural ED nurse

must be competent in his/her skills. This also pushes the need for more research to be

specifically targeted at rural hospitals so that feasible solutions may be found. The lack

of financial stability, smaller staffing ratios, higher acuity patients, and fewer resources

must be taken into account when studies are performed in this area.

Nursing schools must begin to expose students to the rural environment to help

with filling the nursing shortage in this area. By exposing students during their nursing

clinicals maybe more nurses will take that first job in a rural area. There also should be

some curriculum based on rural nursing as a specialty. Exposure to this environment

before graduation will help to build and strengthen a well functioning workforce, which

is an essential building block to the healthcare framework. The rural nurse be

knowledgeable as he/she has to be able to practice without the support urban nurses

expect, use a generalist thinking system, and not only manage a situation, but be able to


anticipate what symptoms might mean to many systems (Molinari, Monserud, &

Hudzinski, 2008).

Recommendations for Improvements

The overall goals and proposed outcomes of the Quality and Safety Education for

Nurses (QSEN, 2011) is to provide future and graduate nurses with the tools they need to

continuously work towards improving the quality and safety in their workplace by

implementing the necessary KSAs or knowledge, skills, and attitudes. The competency

areas focused on by the QSEN include patient centered care, teamwork and collaboration,

evidence based practice, quality improvements, and informatics. This means that we as

nurses must continuously strive towards improving the care we give to our patients. Lets

focus on the area of evidence-based practice. The concept of rural nursing seems to be a

relatively newly examined topic. More research needs to be performed so that nurses

providing care in this area can better their practice and strengthen the quality of the care

they give. This will also help with patient centered care as more literature and research is

done on rural nursing and rural health systems improve the competency in all of these

five areas.

The ANA standards of professional performance that have a large effect on rural

nursing include quality of practice, evidence based practice and research, and education.

Quality of Practice is defined as the registered nurse contributes to the quality of practice

(ANA, 2010). Rural patients make up about 20% of the patient population. This is a

large percentage and one that deserves to be focused on. By including curriculum about

rural nursing and ongoing research the quality of care given in this area will be improved,

as the knowledge base surrounding rural nursing will be expanded. Going along with


education, Nursing schools need to expose students to this environment to help with

filling the nursing shortage in this area. By giving students the opportunity to learn what

rural nursing is all about the likelihood of recruiting nurses to this area of work will

improve. Rural nursing is a highly skilled area and one that can be very rewarding. Also

expanding the educational opportunities available to the rural nurse is a must. Rural

hospitals need to recognize the need for ongoing education and provide their nurses with

appropriate access whether this be through online classes, seminars, conferences, or the

hospital’s own educational department. Education must be a priority.

Since Long and Weinert originally introduced the rural nursing theory little has

been done to sufficiently test their ideas; what little has been completed is fragmented

and lacks a solid foundation, this specialty needs to advance the state of the science and

produce higher levels of evidence so that solid clinical practice guidelines can be

produced (Williams et al., n.d.). It seems that although the specialty of rural nursing is

advancing the evidence based practice behind it continues to be insufficient. When more

research and education is focused on this topic we as nurses can ensure that the quality of

our practice is improving and has a solid base to support it.

Conclusion

In conclusion the specialty of rural nursing is growing exponentially, but the

research and evidence based clinical practice guidelines are lacking. The rural nurse has

long been overlooked and it is time that both education and exposure to this field are

expanded. The rural nurse is responsible for patients whose age range is as diverse as the

patient’s disease processes. The rural nurse must be a generalist meaning that he/she

must posses a wide array of knowledge of disease processes and how to mange them


efficiently, effectively, and without the same resources the urban nurse is accustomed to.

During one shift a nurse may have to manage multiple patients with a high acuity and

multiple disease processes. “The rural generalist performs crisis management in six

nursing subdisciplines: pediatrics, obstetrics, psychiatrics, geriatrics, medical or surgical,

and emergency nursing” (Molinari et al., 2008, p. 43). In order to practice rural nursing

according to QSEN and ANA guidelines a solid foundation must be built from the ground

up. It needs to be recognized that the rural nurse faces unique situations that differ

greatly from those practicing in the urban environment. The role of the rural nurse is

only going to continue to grow and expand and cannot be ignored or overlooked any

longer.


References

American Nurses Association. [ANA] (2010). Nursing: Scope and standards of practice

(2nded.). Silver Spring, Maryland

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.

McCoy, C. (2009, March). Professional development in rural nursing: Challenges and

opportunities. The Journal of Continuing Education in Nursing, 40(3), 128-131.

Molinari, D. L., Monserud, M., & Hudzinski, D. (2008, January). A new type of rural

nurse residency. The Journal of Continuing Education in Nursing, 39(1), 42-46.

Nursing Theories: A Companion to nursing theories and models. (2012, February).

Dorothea orem’s self-care theory. Retrieved from

http://currentnursing.com/nursing_theory/self_care_deficit_theory.html

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Area Criteria. Retrieved from http://www.census.gov/geo/reference/ua/urban-

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Van Vonderen, M. L. (2008, July-September). Managing rural emergency department

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Western Pacific World Health Organization. [WPRO] (2013). The WHO health systems

framework. Retrieved from


http://www.wpro.who.int/health_services/health_systems_framework/en/

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Whitney, J. R., Werner, S., Wilson, S., Sanddal, N., Sale, P., Mann, C., & Nemec, J., …

Hartford, D. (2010, July). Rural trauma and emergency medical service

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Williams, M. A. (n.d.). Rural professional isolation: An integrative review. Online

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apgall.weebly.com · Web viewRural Nursing: Issue Analysis. Amber Paige Gall. Ferris State University. Abstract. Rural nursing is a recently newly examined topic, but a rapidly