In a work environment with limited resources one of the most influential resource is you the nurse. Yes, that’s right we are a health care resource and it’s about time it we view ourselves as one.
When I worked at a larger hospital, I didn’t understand the concept of social justice, you needed care you received care, there were plenty of resources to go around, and as a nurse, if I was sick, I was replaced. If there was a mass amount of people in the ED who needed to be admitted, you discharged home or overflows were opened. That all changed when I came to rural medicine. Suddenly, if a nurse was sick, and couldn’t be replaced we talked of shutting down our ED and inpatient unit. That means a town of 3000 people go without acute care services. WOW it blew my mind, and it did happen. My second week as a rural nurse we had to close the hospital and my view of nursing changed. It immediate turned political, and I found myself as nurse in the cross fire.
I have been working as a rural nurse for over seven years now and my stomach still turns when the phone rings. Will I have to come in for a critical case? Is there a short call? How will I say no? Most of the time I don’t say no to working overtime or coming in to help, but that isn’t the best for a balanced work and life schedule, however, it’s important to understand that saying no has social implications. Check out my post on the 10 Challenges and Benefits of Being a Rural Nurse, for more information on what its like to work as a rural nurse.
Registered Nurses are extremely valuable to the health care system, an ED can operate with out a doctor but not without an RN. It would seem to the outside world that RN’s are extremely powerful, but our voices are rarely heard, and support is limited. I can’t say for sure as to why we have become so powerless with our increasing duties and expectations, but it is a phenomenon that affects every sector of care. What I can offer is an honest account of social justice and how as a rural nurse you can incorporate this into your practice and give some reference to your dedication.
- View yourself as a Health Care Resource – just like the ventilator or another piece of medical equipment we are as nurses just as practical and valuable. Even more so, because our role in rural health care is so immense and we are constantly having more added to our plate. I have found it bizarre that other health care professionals can say no. It’s not “in their scope” or in their job description; but as a nurse it some how becomes your role and job whether you like it or not. Our professional standards tell us we have a Duty to Care, while also, telling us that we must be Fit to Practice, this at times in the rural setting is an oxymoron or a fine balance.
- Put your Health First – I have been there, working sick or feeling emotionally unwell, but you do it anyways. We call it dedication but really this behaviour threatens the culture of safety that health authorities are trying to convey. So why do we do it? Because we as rural nurses’ fear that our illness could jeopardize the care of our patients. The hospital may have to close, or a colleague will have to work extra to cover. It’s the reality but at the end of the day it’s not safe to work sick, that too is risky. It could be argued but I feel rural nurses, hide a human resource problem because of the closeness of our professional and personal lives. I wouldn’t dare call in and live with a hospital closure as I have family in this community, what if my mother-in-law had an asthma exacerbation? Or great-grandpa had a stroke? It’s easy to have dedication blur the lines of professional responsibility, we know we must be fit for practice, but do we practice what we preach? In rural sites, no I don’t think we do. We still believe that having someone is better than no one, however, as nurses we need to acknowledge this. Putting your health first doesn’t mean negating your community or you lack dedication it means you are thinking of your roles as nurse being more than just a job to fill.
- Prioritize your Time – I watch new graduate nurses who are just starting their journey both as a nurse and as a rural practitioner and there is a common theme. They have no concept of time management – not time management in terms of organization, but time management in the light of you being the health care resource. Is it appropriate for a nurse to negate her patient assignment to attend to one patient? In a large centre of course, because you have other staff to take care of your assignment. In rural health care, no it’s not. You must acknowledge that you are the resource and you need to allocate your time wisely. Here is an example, a near drowning victim comes into the ED. He needs to be intubated and vented, he needs one-to-one monitoring. The transport needs to be booked and labs entered, etc. The list of tasks goes on. All staff are present to help this young patient. An elderly man is admitted to the floor for delirium related to a bladder infection, he has a defined trajectory, and treatment is underway. He is in his nineties. All hands are on deck for the young patient, and he is transferred for a higher level of care and survives. The elderly patient has a fall in his room, while his nurse is attending to the critical case, he dies as a result of a fractured hip. Where is the social justice? These are scenarios that can occur in rural sites, sometimes, some else’s care affects the care of another. The time you give patients means that another patient goes without your time, and unfortunately it can be fatal. There is no right or wrong in this case, but it does give you insight into what social justice looks like. And for those new to the game of rural nursing it holds a valuable lesson, prioritize your time wisely. That’s why negotiating and delegating your work is important.
- Negotiate and Delegate – When a task is time consuming, stop and think, “is there some else who could be doing this job?” The answer most of the time will be yes, you can delegate your duties so that you are doing the task that are unique to your scope and vital to the health of your patients. It’s easy as a rural nurse to feel like you must do it all, but do you? Perhaps it’s as simple as delegating or asking for help, what is a reasonable solution for you? Find a solution and bring it forward to the decision makers in your facility you may be surprised at the eagerness of management to help you negotiate or delegate your tasks.
- Be Political – This is uncomfortable for some nurses. But as a rural nurse you are forced to be political. You are valuable to your community so use your political power and share your issues. What is affecting the social justice in your community? How can the political environment aid in these issues? You can be both political and belong to a profession and health authority, I know nurses can be timid and don’t want to speak on behalf of your workplace, but you don’t need to. Yes, be aware of communication policies of your site and authority but do not feel like you can’t engage in the political processes. Vote in elections, share your concerns at town meetings, join committees or stakeholder groups. The beauty of a small town is that it’s so attainable and grassroot movements are powerful and vital to sustainable rural life. We have the ethical obligation to think about larger systems at play in terms of health. Does your community have fresh water, access to food security, supported sexual orientation programmes? These all will affect the health of our communities and is a nursing responsibility. Regardless of where in health care we work it is our duty to care. The CNA (Canadian Nurses Association) has a great document regarding social justice, so check it out HERE.
- Look Beyond Direct Care – I may provide acute care services, however, what affects my patients is so much more than acute illness. I feel the effects when there isn’t home health coverage on the weekend, or when the Long-Term Care facility is short staffed. I see an increase in visits when the air quality is poor because of wild fires, or rivers flooding. A skilled rural nurse can look at her patients in a broader perspective. Seems ironic, that a small site gives a better perspective on macro concepts of care, like the determinates of health. To be a proficient rural nurse you need to recognize what is really affecting the health of your patients in order to provide optimal support.
- Examine Oppressive Structures – Because rural nurses also live in the communities where they work, we tend to have a realistic account of what affects our patients. Travel, for example, is a huge barrier to healthy rural communities. Geographic isolation can lead to death in certain cases. Nurses need to acknowledge oppressive structures or systems that can systematically disadvantage our patients. Once you identify what’s affecting your patients, then you can start to capacity build the community to bridge these disparities. At my site our physicians have been active in recruiting visiting specialist to come to our community so that our isolated patients don’t have to travel for appointments. Sometimes it just takes some creativity and innovation by the people on the front-line to bridge these gaps.
I am no expert on social justice but living and working in a small community has given me a solid lesson in ethics from so many perspectives. I have been a pregnant woman living with travelling to maternity appointments, I am a wife of a man who get spontaneous anaphylaxis whose life could be jeopardized if we had no acute services because of lack of staff. I am the staff who works sick, overtime, and struggles to bring a balance to my life and work. That’s why I make a contentious effort to incorporate these concepts of social justice, so we all get the care we deserve.
