Five Reasons Rural Nursing is a Forgotten Speciality

I couldn’t get a hold of the doctor and the patient was in cardiac arrest, so I ran the cardiac arrest algorithm for a half hour with out a physician. Shocked him seven times and used all the epinephrine we had in the building, but nothing could bring him back. And, as I looked over at his unkept intoxicated spouse, who spat at me with missing teeth. He’s dead? Couldn’t you save him? I thought, this pretty much sums up rural nursing – no doc, no social work, no team, just me and the crew that brought him in.

I have been a rural nurse for six years and in those years, I have developed a unique set of skills that in my opinion has made me a renegade in the nursing profession. Because of geographic isolation and social exclusion from nursing dialogue in general, I feel rural nurses need to tell the world what it means to walk this unbeaten path of medicine. But why are we a forgotten speciality?

1. No One Knows What We Do

I remember it like it was yesterday, the 20 minutes we spent in my nursing program that explored rural nursing. Like literally we read one 40-page chapter in a book that introduced us, as nurses, to rural health. 40 pages to describe a topic so complex and so vast, it’s no wonder that rural areas suffer from retention and recruitment issues – no one knows what we really do.

The truth is rural nurses do it all, we are trauma nurses, cardiac nurses, perinatal, palliative, and addiction specialists. You name it we must do it – generalists in a specialized world. That is one of the reasons I fell in love we rural nursing, never a dull moment, never a chance to get bored. But you need to be a special type of nurse. One who spends countless hours keeping your skills up for the off chance that you may have to use that skill at some point, maybe in a year maybe two. We don’t get the quantity of cases but quality for sure. I can go many months with out a trauma case then BANG a head on collision comes in with three trauma patients. This adaptability is a challenge but also is stimulating and keeps me engaged to my practice.

Rural nurses do more with less, less staff, less equipment, less options. But the care we give our community is unlike any I have ever seen. I started my nursing career in a tertiary care centre in the heart of a city. We had everything at our finger tips to offer patients. Specialists, allied health, fancy new equipment with all the bells and whistles, but we couldn’t provide patient centre care in every sense of the word. Patients to me were a room number and I felt like another cog in the wheel of health care, never really knowing my worth, going from task to task. In a rural setting we know everything about our patients, who they married, divorced, etc. What medication or intervention works best. We know all the bizarre uniqueness of our patient’s medical history, all the details and nuances that make each patient an individual. You see the fruits of your labour. You lyse a STEMI and week later you see him out for lunch, with his two grandkids, you see who your patients really are – the teacher, the mayor, the check-out lady. We know the needs of our patients because we live it too. We know the disparities of rural health care and I feel we lack the support to advocate for dialogue.

2. Not a lot of Dialogue on Rural Issues

It’s no surprise that if most of our colleagues and peers don’t know what rural medicine is about, they certainly can’t understand our issues. I read the journals put out by my regulatory body and union, and although there is some fascinating topics and news, there is little I find relatable. Most of the discussion on rural health focuses on gaps or lack of services. That’s unfortunate because there is profound innovation and flexibility that is happening in rural and remote areas; and, if explored could benefit even larger centres.

One of the greatest issues affecting rural health care is retention and recruitment of all professionals. In nursing, it has been estimated that only eight percent of nursing students (undergraduate) are exposed to rural practice (Oosterbrock, Yonge, & Myrick 2017), this lends to the importance of nursing mentorship and preceptorship. Recruitment needs to focus on uniqueness of rural practice and give students the chance to experience it. So really, rural nursing is a topic that is better experienced than read about in a textbook, however, many front-line rural nurses are silent and disengaged with this process.

3. Silence from the Front lines:

We need to break the silence, we need to find cleaver ways to show the world what rural nursing is all about. Our voice needs to be loud because we all know that the squeaky wheel gets the grease, and with a facility of 4 RN’s verses a facility of 52 in one department our issues seem petty and statistically insignificant. I feel there is a lack of representation because realistically rural nurses deal with staff shortages on a regular bases and tend to work longer hours than urban counterparts. If you already have worked your regular set, and overtime, there is not much left to advocate for your profession and still keep your sanity.

The other phenomenon is that when you are in the thick of it, sometimes it difficult to really see the problem. My experience is that rural nurses are used to doing it all with limited support and we think well that’s just the way it is, and we suffer though.

4. Not “Sexy” Enough

I hate to say it but there is mainstream nursing and rural is not mainstream, where totally indie. Rural nursing isn’t considered sexy by professional standards, we are more of the dishevelled chick in the dated outfit, hoping someone will notice her amazing personality. We lack the toys that are cool, the stuff that is cutting edge. At my facility we just upgraded our tonometer used to check for narrow angled glaucoma in eye emergencies, the old one we had had to be calibrated to the menstrual cycle of a virgin women. Just kidding but that was our joke, it looked like it belonged in a museum – but we saved eyes with it. We got the job done.

To me the sexiest part of medicine is being able to work to the fullest of my scope of practice. However, its not so alluring working long hours with a heavy workload. Nurses and other HCP are demanding work-life balance and unfortunately rural medicine can negatively impact a nurses’ sense of balance. We traditionally work more than urban nurses and we take on-call so even if you’re not at work you are committed to coming in if a critical case requires you to.

5. You must be a Renegade

There are nurses who like order, things done to standard, and have defined responsibility, and that’s awesome. However, that’s not rural nursing. Yes standards are the backbone of our job but in certain circumstances unrealistic to obtain.

I had an interesting experience with the orientation of a new hire that came from a larger center in the city. We had of course a horrible shift, we had a COPD (chronic obstructive pulmonary disease) exacerbation that needed to intubated, and a pediatric sepsis case. She was totally overwhelmed and hours later after we had successfully transfer our patients and got them to a higher level of care, she looked at me with wide eyes “I didn’t hang the midnight IV antibiotics in room 8 it’s now 3 am, that’s a med error, I need to report this”. I looked at her with the same wide-eyed expression. Yes it is, but you could not have possibly have hung those antibiotics you had an airway and circulatory emergency in the ED that trumps the floor with admitted inpatients with a defined medical trajectory. That was too unsettling for her and that was it.

As you can appreciate there are many factors contributing to the lack of appreciation rural nurses get for their work. Being marginalized by geographical location and political talk in nursing, really calls upon rural nurses to rebel against the mainstream thought and challenge the status quo. This is the intent of this blog, to get nurses and other health care professionals to think about rural medicine and talk about rural issues. Even if you don’t work in a rural area I am sure most nurses have looked after patients who live in either a rural or remote community and can discuss accessibility and equality of health care.

So we need a make-over and we need to bring attention to the awesomeness of rural medicine and power of being a generalist.

Leave me your comments and stories and lets collectively examine what rural nursing is about.