Dr. McCoy is Associate Professor, School of Nursing, Troy University, Troy, Alabama.
Address correspondence to Cindy McCoy, RN, PhD, BC, 400 Pell Avenue, Collegeview Building, School of Nursing, Troy University, Troy, AL 36082.
The word rural often conjures up images of the idyllic life of small town America. Although demographics have shifted and urban and suburban areas have grown, the number of individuals living outside metropolitan areas remains significant. The picturesque life imagined does not usually include thoughts about nursing care; however, approximately 51 million Americans living in rural areas (U.S. Department of Agriculture [USDA], 2003) require health care.
Providing nursing care in any setting presents both challenges and opportunities. The purpose of this article is to examine the uniqueness of nursing in the rural setting and to describe the challenges to and opportunities for professional development commonly encountered by rural nurses.
According to the USDA, the definition of rural was updated in 2000 to reflect the most current information provided by the U.S. Census. To define rural, urbanized areas and urbanized clusters must also be defined. An urbanized area is defined by the Census Bureau as having an urban nucleus of 50,000 or more individuals, and having a population density of 1,000 individuals per square mile. It may also contain adjoining territory with at least 500 individuals per square mile. An urban cluster is an area with a population of at least 25,000 but less than 50,000. According to these definitions, rural areas exist outside the urban areas and the urban clusters. In the 2000 Census, 21% of the population lived in the rural areas, 68% in the urban areas, and 11% in the urban clusters (USDA, 2003).
Rural Nursing Theory
The differentiation between urban and rural nursing may not seem important, but “because nursing is a social phenomenon shaped by the society in which it is practiced, an understanding of rural persons along with their self-defined needs and preferences is essential to the development of a theory base for professional practice” (Bushy, 2000, p. 34). Long and Weinert laid the groundwork for the development of a rural nursing theory in 1989 with their definition of rural nursing as “the provision of health care by professional nurses to persons living in sparsely populated areas” (p. 3). The expansion of this definition to include the core concepts of rural nursing has served as a basis for the construction of the rural nursing theory. According to Long and Weinert, the core concepts of rural nursing are “work beliefs and health beliefs, isolation and distance, self-reliance, lack of anonymity, outsider/insider, and old-timers/newcomers” (p. 7).
Rural nursing theory is composed of three major relational statements described by Long and Weinert (1989). The first statement is that “rural dwellers define health as primarily the ability to work, to be productive, and to do usual tasks.” The second statement is that “rural dwellers are self-reliant and resist accepting help or services from those seen as outsiders or from agencies seen as welfare programs.” The third relational statement is that “health care providers in rural areas must deal with a lack of anonymity and much greater role diffusion than providers in urban or suburban settings” (pp. 9–10). Rural nursing theory is well defined by expanding these statements and defining health, nursing, environment, and humans in the context of rural nursing.
Challenges in Rural Nursing
Rural nurses face issues that differ from those of their urban counterparts. These challenges are evident in the amount and type of educational preparation experienced by and the availability of continuing education for rural nurses. Other challenges are associated with cultural and social components of life as a nurse in a rural community, and the nurse’s use of research and evidence-based practice.
The rural nurse is a generalist, but must also have knowledge of specialized areas. This can present several challenges. Many schools of nursing attempt to expose students to the more complex and highly technical aspects of patient care, which is essential for a nurse working in a large urban hospital. However, the skills required for nurses working in a 30-bed hospital in a remote area will differ from those required for nurses working in a 12-bed unit in an urban area. The resources for staff development and orientation may be scarce in smaller hospitals, resulting in a limited orientation for newly hired nurses (Squires, 2002).
Clinical competence is challenging in any nursing setting, but the continuing education and proficiency of nurses in the rural setting may be difficult to maintain due to limited resources (Trossman, 2001). Although many states mandate continuing education to maintain licensure, rural nurses may have difficulty meeting these requirements. Limited resources in the rural agency may be evident in the lack of financial expenditures for continuing education and scheduling. For example, allowing nurses to attend continuing education courses may create budgetary strain, or there simply might not be other nurses available to cover shifts.
In addition to limited resources, several other factors restrict rural nurses’ access to continuing education. These include travel time and distance to educational programs, cost, work schedules, reluctance to be away from family, limited awareness of educational activities, and topics not of interest (Beatty, 2001; Hendrickx, 1998). Due to these limitations, rural nurses may complete their continuing education hours in ways that do not meet their needs or that do not effectively contribute to their continued clinical competence (Hegge, Powers, Hendrickx, & Vinson, 2002).
Cultural and Social Differences
Rural communities differ culturally and socially from urban or suburban communities. In rural settings, it is “a cultural expectation of many rural people to be taken care of by someone they know” (Scharff, 1998, p. 193). As a resident in the community, the nurse is likely to know a patient in several contexts. This level of knowing patients has both positive and negative facets. In some instances, the nurse may know the patient socially, or through community activities. The cultural expectation of knowing patients personally can have advantages. Most rural nurses believe that when they personally know patients, they can give better care (Scharff). In rural settings, nurses are more likely to be visible members of the community. Therefore, they may be more aware of patients’ backgrounds and resources and thus supportive, having a greater connection with patients.
Personally knowing a patient can also have disadvantages. It can lead to lack of anonymity for the nurse, ethical situations related to confidentiality, and role strain for the nurse. Nurses in Long and Weinert’s (1989) study reported feeling “as if they were always on duty” (p. 12). When nurses know sociocultural information about patients unrelated to their health care needs, it may be more difficult for them to remain nonjudgmental and professional. In addition, patients’ knowledge of nurses may create a barrier in care from patients’ perspective. Regardless of the level of knowledge, rural nurses must maintain respect for community traditions and cultural differences at all times (O’Brien, Anslow, Begay, Pereira, & Sullivan, 2002).
Research and Evidence-Based Practice
Knowledge of the research process is essential to development of nursing in any setting (Bushy, 2004) and nurses are increasingly turning to evidence-based practice. In rural nursing, a scarcity of research initiatives exists. This may be due to limited resources and heavy workload (Bushy). Olade (2004) identified the following barriers to participation in research use: “lack of time because of poor staffing, lack of research knowledge, lack of interest of nursing administrators, lack of financial resources and organizational support, isolation from nurse researchers, lack of research consultants, and lack of experienced nurses to serve as role models for research utilization” (p. 221). Nurses in the rural setting must have access to the tools necessary to conduct, access, and use research.
Opportunities in Rural Nursing
Despite challenges for nurses working in rural settings, many opportunities also exist. The rewards of delivering nursing care in this setting can be very fulfilling.
Strategies to meet the educational needs of rural nurses are not simplistic and require the collaboration of nursing leaders in the rural setting and the educational setting. Kenny and Duckett (2003) suggested that nurses receive better preparation at the undergraduate level in leadership and management, mental health, assessment skills, and advanced life support. Additional areas for educational preparation include knowledge of change theory and a solid basis in nurse generalist skills. To better prepare nurses for work in the rural setting, nursing schools may need to examine graduates’ postgraduation employment data and incorporate clinical experiences in the rural setting into the curriculum as appropriate. For example, arranging student clinical experiences in a home health agency for rural and urban settings so students can compare and contrast the two would be beneficial. Other educational opportunities exist when nurse educators have students participate in health promotion activities delivered in the rural setting. For schools of nursing located in areas that are primarily urban or suburban, creating partnerships with similar programs located in rural settings could provide for an exchange of student experiences that would be mutually beneficial. Arranging for service learning projects through local agencies in rural areas where no nursing school exists is another method for exposing students to this setting and preparing them to work in this area.
To be successful lifelong learners in a somewhat isolated environment, Long and Weinert (1989) recommend that rural nurses develop strong skills in information retrieval. In this age of connectivity, nurses must have the skills to find and analyze useful information for practice and for patient education. Including courses and activities in the nursing curriculum to develop and strengthen these skills would be beneficial. For example, incorporating an activity on finding research articles in Internet-based electronic databases into a research course would enhance nurses’ skill in information retrieval. Introducing student nurses to the field of nursing informatics would also be beneficial.
In addition to the educational preparation of entry-level rural nurses, there is a definite need for continuing education partnerships that will provide relevant, timely, and environment-specific programs for the rural nursing community. Scharff (1998) identified the greatest educational needs of rural nurses as cardiac, trauma, maternal-child, and complex medical nursing. Rural-urban collaboration in continuing education can be beneficial to rural nurses by providing access to programs such as advanced cardiac life support, pediatric advanced life support, and neonatal advanced life support (Malay & Moore, 2002). During the past decade, the number of large urban medical centers that have absorbed rural hospitals in an effort to enhance patient care has rapidly increased. These mergers provide excellent opportunities for partnerships among nurse leaders and educators in either setting to share knowledge and expertise.
As urban or larger agencies form financial partnerships with rural agencies, the opportunity for nurses to network and form mentoring relationships increases. Mentoring in nursing has become one of the most valuable tools in professional development. Using this strategy to aid rural nurses could be beneficial.
In the creation of mentoring relationships, collaboration among professionals could include mentors in academic programs, mentors in urban areas, and experienced rural nurses (Gibb, Anderson, & Forsyth, 2004). Using mentors from areas with more resources could create strong mentoring programs; therefore, both the rural nurse mentees and the mentors would benefit. One method to accomplish this collaboration is through networking in specialty nursing organizations. These organizations are in a position to facilitate this through networking efforts of their members.
Cultural and Social Opportunities
Nurses in the rural setting often integrate into the community, which is generally small and intimate. This close-knit environment is a positive factor. Clearly, supporting the rural nurse’s role in the community is significant for the entire spectrum of nursing leaders. To do this, there can be initiatives by rural nurse leaders or administrators to promote the professional image of the nurse in this environment, and to emphasize to the community the importance of the nurse in health care. Through education of the community about the knowledge and training that professional nurses possess, residents can view nurses as more than just “friendly neighbors.” The first step in this strategy is using publicity and informational material to educate the public about educational preparation, licensure, and expertise of nurses. The local and state nurse’s association would be the logical organization to use to initiate this process.
Strategies to promote evidence-based practice in rural nursing are imperative. Rural nurses need access to research and information on how to read, interpret, and use research findings in clinical practice. One excellent method to accomplish this would be the formation of research partnerships with universities (Bushy, 2000). According to Persily (2004), these relationships provide a rich environment that can “influence education, promote research, and facilitate provision of high-quality, evidence-based care” (p. 76). Additionally, there is a need for research from the rural nurse’s perspective regarding the realities of being a rural nurse (Rosenthal, 2005). This perspective is important to recruit students and experienced nurses in the rural setting, enhance the esteem of rural nurses, and elevate rural nursing to a specialty within the practice of professional nursing (Rosenthal).
Nurses in the rural setting also need access to and training in how to use electronic resources to obtain information regarding evidence-based practice. Computers with Internet access, personal digital assistants (PDAs) with reference manuals, and other emerging technological tools must be accessible. Although some areas provide access to electronic resources through virtual libraries, rural nurses may need additional training to use those resources.
Nurses working in the rural setting are an essential component of the health care system. In many instances, the rural nurse is the most significant health care provider for a patient. Due to the nature of the rural setting, nurses face challenges for maintaining professional competence and continuing their professional development. It is vital, not only for the nursing profession, but also for overall patient care, that nurse leaders and educators identify the professional development needs of this group and strive to meet those needs. As nurse leaders and educators continue to examine rural nurses, the importance of identifying creative strategies to meet their needs will be emphasized. Using initiatives such as those described in this article, the professional development challenges can be minimized and the opportunities realized.
- Beatty, RM. 2001. Continuing professional education, organizational support, and professional competence: Dilemmas of rural nurses. The Journal of Continuing Education in Nursing, 32(5), 203–210.
- Bushy, A. 2000. Orientation to nursing in the rural community. Thousand Oaks, CA: Sage.
- Bushy, A. 2004. Creating nursing research opportunities in rural healthcare facilities. Journal of Nursing Care Quality, 19(2), 162–168.
- Gibb, H, Anderson, J & Forsyth, K. 2004. Developing support for remote nursing education through workplace culture that values learning. Australian Journal of Rural Health, 12(5), 201–205. doi:10.1111/j.1440-1854.2004.00605.x [CrossRef]
- Hegge, M, Powers, P, Hendrickx, L & Vinson, J. 2002. Competence, continuing education, and computers. The Journal of Continuing Education in Nursing, 33(1), 24–33.
- Hendrickx, L. 1998. Continuing education and rural nurses. In Lee, HJ & Winters, CA (Eds.), Rural nursing: Concepts, theory, and practice (2nd ed., pp. 248–256). New York: Springer.
- Kenny, A & Duckett, S. 2003. Issues and innovations in nursing education: Educating for rural nursing practice. Journal of Advanced Nursing, 44(6), 613–622.
- Long, KA & Weinert, C. 1989. Rural nursing: Developing the theory base. In Lee, HJ & Winters, CA. (Eds.), Rural nursing: Concepts, theory, and practice. (2nd ed., pp. 3–16). New York: Springer.
- Malay, ME & Moore, JF. 2002. Rural-urban partnering in continuing education. The Journal of Continuing Education in Nursing, 33(2), 60–63.
- O’Brien, BL, Anslow, RM, Begay, W, Pereira, BA & Sullivan, MP. 2002. 21st Century rural nursing: Navajo traditional and Western medicine. Nursing Administration Quarterly, 26(5), 47–58.
- Olade, RA. 2004. Evidence-based practice and research utilization activities among rural nurses. Journal of Nursing Scholarship, 36(3), 220–225. doi:10.1111/j.1547-5069.2004.04041.x [CrossRef]
- Persily, CA. 2004. Academic nursing practice in rural West Virginia. Journal of Nursing Education, 43(2), 75–77.
- Rosenthal, K. 2005. What rural nursing stories are you living? Retrieved June 28, 2006, from www.rno.org/journal/issues/Vol-5/issue-1/Rosenthal_article.htm
- Scharff, JE. 1998. The distinctive nature and scope of rural nursing practice: Philosophical bases. In Lee, HJ & Winters, CA. (Eds.), Rural nursing: Concepts, theory, and practice (2nd ed., pp. 179–196). New York: Springer.
- Squires, A. 2002. New graduate orientation in the rural community hospital. The Journal of Continuing Education in Nursing, 33(5), 203–210.
- Trossman, S. 2001. Rural nursing anyone? Recruiting nurses is always a challenge. American Nurse, 33(4), 1–4.
- U.S. Department of Agriculture. 2003. Measuring rurality: What is rural? Retrieved June 29, 2006, from www.ers.usda.gov/briefing/rurality/WhatisRural