It was a good thing that I didn’t know what I was getting myself into. I knew nothing about rural nursing – I literally googled it.
But even google couldn’t describe this area of expertise, which upon reflection worked out, because if I knew the challenges and idiosyncrasies, I may have never left the city. And that would have been a great loss for myself and my family.
There is great beauty and simplicity in rural nursing that can’t always be described, perhaps that why google couldn’t even answer my search question. What I did find was……………..
Blah, blah, blah geographical isolation blah, blah, weather…………basically not a lot of defining that goes beyond the physical layout of the land.
One definition that spoke to me was……..
“Being a rural (remote) nurse means being able to deal with what she or he has got, where she or he is, and being able to live with the consequences.” (Scharff, 2006, p. 181).
Wow that’s it – especially the part about living with consequences.
I hear her voice when I am struggling to complete ten tasks at once and I am getting pulled in five different directions, “you can only do the best with what you have.” My mentor to rural nursing is dead on, and it’s a mantra I continue to share with new hires. That’s the challenge you must accept and understand that rural nursing is unique, and we operate with a different set of rules and expectations. Getting to the point where you feel comfortable with what you have done and how you have done it is the learning curve.
It’s no wonder that rural nursing is a forgotten specialty, we quietly sit at the sidelines waiting for our turn to shine. Living rural life and working in it professionally offers many inimitable challenges and benefits that need to be shared with the nursing world.
- Living and Working in a Small Community
- CHALLENGES: There is no where to shop. Haha just kidding, well I am not kidding, but this isn’t the biggest challenge of living in a small community. And if I just lived here that might be ok, but I also work here. After a difficult set, I may not go to the grocery store out of fear I will see a certain patient or family member. I isolate to give myself a break. People aren’t trying to be rude when they stop me downtown to ask a question about their health care, most of the time they say thanks and show appreciation. But these moments happen and it’s a constant reminder of my professional role. Also, there are times when I get stopped for medical advice and this frankly leaves me in a sticky situation. I often tell people “well I don’t have all my “tools” with me, so I can’t really assess you but informally suggest you see your doctor.” It’s not a cop-out but I don’t want to be responsible for giving out the wrong advice. Even if the “problem/concern” is minor people can take things out of context and I don’t want to cross any professional boundaries. The other challenge is getting medical care from the professionals you work with. I close colleague of mine put in my IUD. Yah, that’s right one of the doctors I work closely with had to look and place an IUD in my va jayjay. Just before she inserted it I said “and hey, you didn’t even have to buy me dinner” yah, I am the queen of awkward humor.
- BENEFITS: It’s not always awkward and weird to know all the health care professionals in town, it can be a great benefit. My daughter once had a small piece of glass in her foot that I couldn’t take out at home, as I am pretty much blind as a bat, so I told my hubby to bring her up to work and I would use the big light a magnifying glass to see. Well I ended up having two doctors and three nurses trying to help, like WTF. It was the smallest piece of glass and she was in no medical emergency but that’s how this team works – we take care of each other. Living rural also gives me perspective on the issues that affect my patients. I know what it is like to travel for appointments and navigate a system that is specialty centric. I know it’s difficult to get exercise in the winter with ten feet of snow on the ground and no indoor recreation centre, I can be empathetic.
- Human Resources – fewer nurses per capita
- CHALLENGES: Acute Care, Home Care, Long Term Care, Mental Health, and well the list goes on, are all short staffed. It would seem we increasingly do more with less staff; and furthermore, if another department is short we do their work too. Whatever the human resource problem is, it will inevitably become a rural nursing job or should I say competency. Shift-to-shift, it also means your role is expanded. As a rural nurse working in the Emergency department I am the triage nurse, the bedside nurse, I run ambulatory care clinics, I give support to the inpatient unit, I answer the phones, I enter all my own orders, I do all the ECG’s and interventions for patient care, I make all my own drugs (no pharmacy support), and port patients to wherever they need to go. We literally do it all. Our physicians are no different, they too must run primary care clinics and take turns doing Emergency Call. It doesn’t matter what discipline you work in you will do more than one role when working in a rural area.
- BENEFITS: Your immensely important when you are doing everything, and that’s some solid job security (wink wink). The continuity of care is better too, when you have small team that works closely together and does multiple roles, we really know our patients and their unique health needs. The care is more consistent and patient-centre by default of not having a lot of human resources.
- Maintaining Privacy
- CHALLENGES: So many times that I would love to come home and tell my husband, guess who has a STI! But I can’t. I am being comical, but it’s true, I have to really watch what I say because my husband knows everyone in town, and I don’t want to break any privacy and confidentially. However, it doesn’t take long for the word to get out via old fashion small town gossip. I will come home after work and my husband will say “guess what happened today?”, and he will already know about a big case. But like all rumors the truth is distorted, and it often makes me laugh at what ends up being spewed around town. It’s like that telephone game you played as a kid, but I can’t be the one starting the message.
- BENEFITS: I don’t have to write the benefits of maintaining confidently, it’s the law and we all deserve it.
- Nursing Family and Friends
- CHALLENGES: Every nurse has this issue regardless of where they work, family/friends want unsolicited medical advice. It’s so practical having a nurse in the family to run something by and get their opinion, and frankly, I don’t mind. However, when it comes to professionally treating your family or friend it can get messy. We try to support each other by taking the care over for a patient that may be related to the primary nurse. But it can’t all be avoided. And honestly sometimes we don’t agree with our family/friends and it gets complicated.
- BENEFITS: When you are working the front-line and you interface with a family or friend, you have an awesome opportunity to advocate. If you don’t cross any boundaries you can influence the care your family receives or nudge it in the right direction.
- Geographic Isolation
- CHALLENGES: It happens often, the highway leading from my town to our referral centre closes. This affects ambulance transfers, which can jeopardize patient care, it also can impact who gets to work. And we may have a staffing issue because of a road closure or bad weather. Geographic isolation also has the challenge of time. It takes longer to get to sick people and it takes longer to get sick people transferred. The Golden Hour, the door-to-needle are many ideals we can’t always meet in the dead of winter. And the guy having the big jammer is always the guy who lives 30 clicks from town, on a dirt road that isn’t plowed.
- BENEFITS: If you like reclusive living rural is your place. We have no traffic lights, no crazy intersections, no reasons it won’t take you five minutes to drive across town. You are sheltered from the chaos of the city, of the go-go, mentality that is causing nothing but stress and anxiety. You want to live a less stressful life, move to a rural area. All of the sudden it’s about nature and the passing of seasons, that dictates time – a living apple watch.
- Really Knowing your Patients
- CHALLENGES: There is some great information out there regarding the concept of Cognitive Bias in medicine. It can happen anywhere in health care but it is extremely relevant to rural nursing. So what is Cognitive Bias? It’s flaws or distortions in decision making that can affect patient care (Merck Manual). We all do it, although most of us will deny, cognitive bias is everywhere. Let me provide an example. Being new to rural nursing, I relied and perhaps too much, on my senior colleagues’ judgement of a patient. In one such incidence, an elderly man came in by ambulance with shortness of breath. I did my assessment and found he had no sounds to his lower right lobe in his lung. I told my colleague who had worked in this community for 20 years and she knew this patient well. She said of course he doesn’t he had it removed. The novice in me was pleased with that answer and I didn’t go searching for supporting documentation. Eventually after a chest x-ray he was found to have a pneumothorax, hence no lung sounds, and ended up with a chest tube. Timely intervention was delayed because I didn’t report my findings as abnormal, because I relied on someone else’s misinformation. I vowed it would never happen again. However, when you really know your patients and work so closely with them over many years, it’s easy to distort the objective clinical findings.
- BENEFITS: Being aware of Cognitive Bias is the first step in making good clinical decisions. And knowing your patients inside and out (literally) is a great benefit in providing patient-centred care. We quickly know what interventions work best or what intervention is right for this patient. Nursing is a great resource for when physicians are working at our site who do not live and work in our community, as we know what our patient’s baseline is and if there is a deviation. When you know your community, you can advocate for your patients and families, and offer treatment options that meet them where they are.
- Lack of Recognition by Other Nursing Colleagues
- CHALLENGES: I get upset; I am sensitive to this phenomenon. It’s clear when I go out of town for courses that other nurses don’t get the expertise that is needed to do my job. It’s funny the critical care and ICU nurses group together and talk about ECMO this, dopamine that – it’s all so sexy. Tubes and interventions and continuous monitoring, wow. I would love to see an ICU nurse work in a small department with no Internist and no fancy tools to use. How would she make decisions? Well she would have to rely solely on clinical assessments and judgments. Which makes most specialty trained nurses uncomfortable. I am not begrudging my specialized colleagues, but I argue that rural nursing is a specialty too – and I am just as sexy! With my limited resources, geographical isolation, and outdated technology.
- BENEFITS: Well my big city colleague and specialized peers do recognize that to be a rural or remote nurse you need to be a badass. You need to be a nurse that thinks like a doctor. You need to value autonomy and be comfortable in your skill set, you need to love responsibility and excel with challenges. Benefits to a lack of recognition is that if everyone knew how awesome rural nursing was, I wouldn’t have the job security that I do.
- Less Rules and More Responsibility
- CHALLENGES: Nurses like rules, we like order and systems, we like organized chaos, we love decision making tools and pre-printed order sets. We value policy and procedure – all good things. However, in rural nursing it’s challenging to meet these policy and procedures that were made for a larger centre. And although health authorities try to include rural sites, we still are negated or left to work with guidelines that are not practical. This leaves the rural nurse to adapt to the situation, be flexible, and operate to the broadest of your scope to make it work. At the end of the day, it’s a lot of responsibility without a lot of guidance. Most rural sites also lack the internal infrastructure to support rural practice and mandate our responsibility. We don’t have a lot of site-specific policies, and I often ask why we do something they way we do, and it literally has been passed down from nurse-to-nurse to create an informal procedure. A culture of knowing, rather than a science.
- BENEFITS: There is beauty in culture and organized ways of being, if you desire change you can make change. If I want to optimize some aspect of my workflow or how we provide service I can. I don’t have to go through multiple managers, administrators, and committees to make change. The process is much simpler. For me it also brings care back to being care, not duties prescribed by legalities. I do something because it’s the best care for my patient not because the PPO told me to. Having significant responsibility helps develop leadership skills, forces you learn new things, and have an appreciation for whole system.
- Understanding for Community Capacity
- CHALLENGE: Communities have a large capacity to advocate and use their voice on issues that affect them. The challenge can be that there are times when a community can advocate for one group but negate another. Not out of anything other than ignorance. When our community was faced with hospital closures, related to a lack of physicians, the public rallied, and now we have an awesome group of doctors living and working in our community. However, there has been little community support for the recruitment and retention of nurses. When I came to this community there was a shortage of RN’s and I took a full-time line that couldn’t be filled. I left a job early in the city and had to pay rent on two places to secure housing. I connected with the town council at the time and asked for help with moving expenses. The reply from council was curt and they informed that yes, they do have money for recruitment of professionals, but historically has only been used for physicians. I was pissed, like seriously. But I can’t blame them, being an employee of a health authority can make community engagement and advocacy more challenging. We have unions and communication policies etc. that can make it difficult to access nurses.
- BENEFITS: A group of people can be powerful and by being aware of boundaries you can still seek aid from active public groups. The community also can help to bridge the gap in services that arise from living rurally. Our community has a great foundation of volunteers that help seniors get to and from specialist appointments out of town. Community forums are great tools to impart health promotion and education and help bring to light specific health issues affecting our community, and they are open to the public.
- Mixed Bag – Diversity and Variety
- CHALLENGES: You never know what you’re going to get. And you really get it all some days. However, that is innately challenging as you must perform complex task on infrequent bases. So much to learn, and not a lot of ongoing consolidation. You can feel like a jack of all trades master of none. Not a lot of onsite education happens either, most courses to maintain competency are out of town, or offered online. Not bad options but difficult on a shift-to-shift bases if you needed a quick refresher. I am not going lie, I can be seen YouTubing Chest Tube Insertion prior to helping the doctor – I think YouTube has saved many people in rural areas.
- BENEFITS: Challenges are exciting and keeps you stimulated. Once you get over the fear of what can come into a rural hospital you are given the chance to expand your knowledge and develop your craft. Diversity and variety are the spice of nursing and every shift offers its own challenges that continue to engage and increase the proficiency of clinicians.
I sat down and wrote this article from my lived experience as a rural nurse, then I found this discussion paper, Rural and Remote Practice Parameters. I was amazed at the similarities and gained an appreciated for my professional self. What I experience everyday is shared by many other nurses working in this unique specialty and our practice does call for examination and attention. We are not just the cogs in a wheel of a beastly machine we call health care, we are the beast. Which means we can tame that beast and make him work for our patients.
I have become an autonomous badass nurse who lives daily with all these challenges and benefits and I wouldn’t have it any other way.
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