Should rural nursing be a specialty?

[msn10]

Nurses in rural areas are confronted with very different hospital and clinic cultures than urban nurses. Nurses in rural areas have less resources available to them, less educational opportunities, lack of professional and technological support and a lower number of APNs as well as higher turnover rates (Shreffler, 1998; Winters & Mayer, 2002; Baernholdt, et al., 2010, & Jukkala, Henly & Lindeke, 2008).

However, these nurses are very often trained in urban areas that address urban needs. Practice challenges are very different in rural areas than urban ones and rural nurses are often at a disadvantage because most educational curriculums are based on city hospital scenarios (Baernholdt, et al., 2010) Furthermore, the scope of practice in rural nursing is usually that of a generalist rather than focused on a certain specialty area. Rural populations face unique health issues and disparities and rural nurses must be competent in many areas of care on any given day in any given unit.

So my question to the rural nurses out there is "How do you feel about your practice? Do you ever have feelings of isolation or regret for going into the nursing field? If you have worked in both urban and rural areas, how are they different? What would you like to see changed?"

As an educator who does train some rural nurses, I often wondered if rural nursing should have special training.

[linearthinker, DNP, RN]

I've worked in both. Having fewer resources presents a lot of challenges, but city mouse, country mouse, at the end of the day I find the job about the same. So no, I don't think rural nursing merits a specialty.

[JeneraterRN]

Thank you for a very constructive question! As a rural nurse, the generalist nature is quite challenging. OB has been a particular challenge to gain proficiency because I practice OB perhaps 10% of my time at work. However, I'm not certain it could be effectively taught as a specialty, or that is necessary. A new grad is basically a generalist when they enter the work force and can maintain those areas that are necessary for their region.

[elkpark]

I have done both, also, and would say that I don't support the idea that rural nursing is a "specialty" -- unless we are also going to say that urban nursing is its own, distinct "specialty" ... (And suburban nursing? What about that?)

I started my career by moving from the city in which I trained (at a large, urban, teaching hospital) to a small town in Appalachia to take a job at a small community hospital. Sure, there was some adjusting and adapting to be done, but my basic nursing education had prepared me (well) to be a nurse in most any setting in which I found myself.

[msn10]

Thank you for your responses so far!!!! The IOM and Robert Wood Foundation found so many unique problems in the rural setting that they are proposing a special curriculum for rural nursing like in Rural Healthy People 2010.

They also believe that the 'urban' nurse's educational needs area addressed because most of the nursing schools are in urban areas. When urban nurses work, they usually specialize while rural nurses have to stay generalized which is difficult to do in an ongoing basis. As one nurse stated, 10% of you practice might be OB and then pediatrics, and add in urology and ortho in one day. Keeping up on the latest education in all of those areas presents a problem for many nurses.

Keep the comments coming please!

[EricJRN, MSN, RN]

I guess I'm wondering what you mean by special training. An addition to undergrad nursing curricula? A hospital-specific staff development program? Extra courses or a certification for practicing nurses?

I only worked in a rural setting prn for a few shifts before scheduling and long drives got too hairy. But with specialties in general, I think that a small percentage of the requisite knowledge comes from school, some of it comes from continuing education or "alphabet soup" courses like ACLS or PALS, but most of it will come from actually getting in there and working on the unit for a good while.

[elkpark]

Thank you for your responses so far!!!! The IOM and Robert Wood Foundation found so many unique problems in the rural setting that they are proposing a special curriculum for rural nursing like in Rural Healthy People 2010.

They also believe that the 'urban' nurse's educational needs area addressed because most of the nursing schools are in urban areas. When urban nurses work, they usually specialize while rural nurses have to stay generalized which is difficult to do in an ongoing basis. As one nurse stated, 10% of you practice might be OB and then pediatrics, and add in urology and ortho in one day. Keeping up on the latest education in all of those areas presents a problem for many nurses.

Keep the comments coming please!

I don't have any strong opinions one way or the other about the IOM, but I am definitely unimpressed with the RWJF's track record on suggestions for "improving" nursing. As long as we've got new grads coming out of nursing schools who don't know how to do urinary catheterizations, IVs, and other basic nursing skills, I'd say that's a much bigger problem than whether or not they were exposed to a specialty curriculum on "rural nursing."

[tokmom, BSN, RN]

Thank you for your responses so far!!!! The IOM and Robert Wood Foundation found so many unique problems in the rural setting that they are proposing a special curriculum for rural nursing like in Rural Healthy People 2010.

They also believe that the 'urban' nurse's educational needs area addressed because most of the nursing schools are in urban areas. When urban nurses work, they usually specialize while rural nurses have to stay generalized which is difficult to do in an ongoing basis. As one nurse stated, 10% of you practice might be OB and then pediatrics, and add in urology and ortho in one day. Keeping up on the latest education in all of those areas presents a problem for many nurses.

Keep the comments coming please!

How rural is rural? I work at a critical access hospital. We ship out patients if they need specialists. Having come from large city hospitals, coming to this CA hospital hasn't been any big deal. I think where there might be a problem is a new grad starting at a CA/rural hospital. Transferring to a large hospital might be difficult if they have been rural for a number of years. There would be things they did not do at a rural hospital.

[tokmom, BSN, RN]

I also wanted to add, I think it's easier for a rural nurse to stay current. They have internet, webinars, etc..

[msn10]

I think where there might be a problem is a new grad starting at a CA/rural hospital.

Yes, I should have been more specific. That is the group of nurses I am focusing on as an educator. Rural hospitals (even the critical access hospitals) have a much smaller education budget and they have a great deal of difficulty with doing hospital or unit wide educational seminars because of staffing. There is also virtually no preceptorship or mentorship programs which have proven time and time again to increase retention exponentially. Many times there are no physicians at night and the rural nurse needs to act as PT/OT/RD case manager and social worker at the same time. Furthermore, the internet has proven to increase rural education, but hospital budgets in these areas do not provide proper guidance and reimbursement for said education.

[msn10]

I don't have any strong opinions one way or the other about the IOM, but I am definitely unimpressed with the RWJF's track record on suggestions for "improving" nursing.

I would be curious to ask why you feel this way. I don't have an opinion one way or another, I just see our university getting a lot of grants from them. I have not participated in one of those projects, however. Is there some specific suggestions you are referring to?

[Multicollinearity, BSN, RN]

As a lifelong urban resident transplanted to a rural area, I definately see significant differences. However, I am careful to limit my comments to the specific rural area I just left because this is only what I know. I see significant problems with men dominating women, domestic violence, child abuse, drug and alcohol abuse, obesity, and unhealthly lifestyles. I see more racism than I saw in urban culture.

Before moving to that rural area, I never knew someone personally who had experienced domestic violence; that sure changed. Some of my fellow health care professionals even made fun of my healthy low fat diet and yoga routine just because it's foreign to them. To me rural issues seem to stem from poverty, lack of education and lack of exposure to differences, and lack of opportunities.

It seems to me that life is ~20 years behind the urban culture I came from. What I find so interesting is that so many of the rural residents believe they have an idealic community compared to "the big city" while I see urban culture as less dysfunctional in comparison. On the flip-side, though, I have seem more kindness and neighborly help in the rural area than I ever saw for years in the big city.

For our tiny critical access hospital practice is limited to a very narrow scope. Anything beyond a routine appy for example, is a flight out to the big city. And you've got to hope the 1 surgeon is in town when that appy is needed. Spend some time in our ED, though, and you will see scary things that typically appear in a level 1 trauma center - and you have to deal with it using limited resources until the chopper arrives.

This narrow scope does mean nurses lose some skills; however, the good ones learn their niche and excel at addressing the issues common to rural residents: poverty, lack of knowledge, barriers to healthcare such as traveling long distances, boundary issues due to everyone knowing everyone, unhealthy lifestyles (higher rates of obesity, smoking) etc. Sounds like a niche specialty to me!

I absolutely believe rural nursing could be served by specific nursing education aimed at the elements common to rural culture and living. For one thing, in the rural area I just fled, professional boundaries are nearly non-existent. You will see your doctor and/or nurse at the only grocery store in town, gas station, etc. I saw HIPAA violated. Issues of domestic violence and child abuse are much more prevalent. There are more barriers to health care.