The Journal of Continuing Education in Nursing

Original Article 

Identifying the Educational Needs of Emergency Nurses in Rural and Critical Access Hospitals

Lisa Wolf, PhD, RN, CEN, FAEN; Altair M. Delao, MPH

Abstract

This study was conducted to determine educational needs and identify potentially effective educational modalities for emergency nurses working in rural and critical access hospitals. Although 50% of all emergency department visits to critical access hospitals are low-acuity cases, the 4.0% transfer rate in critical access hospitals is significantly higher than the 1.5% overall transfer rate. Nursing issues include the required breadth and depth of skills needed by emergency nurses in recognizing, stabilizing, and transferring patients who require a higher level of care. Thirty-three emergency nurses practicing in rural or critical access hospitals were recruited for a focus group discussion of educational needs, barriers, and facilitators. The discussion was transcribed, and constant comparison was used to identify themes. Participants identified a need for further education in the care of critically ill patients, those who have undergone bariatric surgery, geriatric patients, those with traumatic injury, and those with mental health issues. Themes included educational isolation and limited availability of resources. Developing and delivering continuing education to this significantly isolated practice community is vital to safe patient care.

J Contin Educ Nurs 2013;44(9):424–428.

Dr. Wolf is Director and Ms. Delao is Senior Associate, Institute for Emergency Nursing Research, Emergency Nurses Association, Des Plaines, Illinois.

The authors have disclosed no potential conflicts of interest, financial or otherwise.

The authors thank Anne Manton, PhD, Margaret Carman, DNP, Michael Moon, PhD(c), Betty Mortenson, MS, Susan Barnason, PhD, and the members of the 2012 Institute for Emergency Nursing Research Advisory Council for their review of this work. They also thank Leslie Gates for her assistance with transcription.

Address correspondence to Lisa Wolf, PhD, RN, CEN, FAEN, Director, Institute for Emergency Nursing Research, Emergency Nurses Association, 915 Lee Street, Des Plaines, IL 60016. E-mail: lwolf@ena.org.

Received: April 11, 2013
Accepted: July 29, 2013
Posted Online: August 23, 2013

Abstract

This study was conducted to determine educational needs and identify potentially effective educational modalities for emergency nurses working in rural and critical access hospitals. Although 50% of all emergency department visits to critical access hospitals are low-acuity cases, the 4.0% transfer rate in critical access hospitals is significantly higher than the 1.5% overall transfer rate. Nursing issues include the required breadth and depth of skills needed by emergency nurses in recognizing, stabilizing, and transferring patients who require a higher level of care. Thirty-three emergency nurses practicing in rural or critical access hospitals were recruited for a focus group discussion of educational needs, barriers, and facilitators. The discussion was transcribed, and constant comparison was used to identify themes. Participants identified a need for further education in the care of critically ill patients, those who have undergone bariatric surgery, geriatric patients, those with traumatic injury, and those with mental health issues. Themes included educational isolation and limited availability of resources. Developing and delivering continuing education to this significantly isolated practice community is vital to safe patient care.

J Contin Educ Nurs 2013;44(9):424–428.

Dr. Wolf is Director and Ms. Delao is Senior Associate, Institute for Emergency Nursing Research, Emergency Nurses Association, Des Plaines, Illinois.

The authors have disclosed no potential conflicts of interest, financial or otherwise.

The authors thank Anne Manton, PhD, Margaret Carman, DNP, Michael Moon, PhD(c), Betty Mortenson, MS, Susan Barnason, PhD, and the members of the 2012 Institute for Emergency Nursing Research Advisory Council for their review of this work. They also thank Leslie Gates for her assistance with transcription.

Address correspondence to Lisa Wolf, PhD, RN, CEN, FAEN, Director, Institute for Emergency Nursing Research, Emergency Nurses Association, 915 Lee Street, Des Plaines, IL 60016. E-mail: lwolf@ena.org.

Received: April 11, 2013
Accepted: July 29, 2013
Posted Online: August 23, 2013

The ability of emergency nurses to rapidly identify clinical problems in patients who are essentially unknown and potentially acutely ill is critical to the provision of safe patient care. In 2010, rural emergency departments (EDs) admitted 8.7% of their patients to their hospital’s inpatient or observational units (iVantage Health Analytics, Inc., 2012). In contrast, nationwide, 15.3% of patients who presented to the ED were admitted to an inpatient or observation unit (Centers for Disease Control and Prevention, n.d.). However, the transfer rate for critical access hospitals is significantly higher than the overall rate for all EDs. Rural hospitals are also unique because many of them are critical access hospitals. The Balanced Budget Act of 1997 created the Medicare Rural Hospital Flexibility Program, a nationwide initiative that established the new category of critical access hospital. These hospitals are eligible for cost-based Medicare reimbursement. A critical access hospital is a limited-service hospital that builds on two programs from the early 1990s: the Montana Medical Assistance Facility Demonstration Project (U.S. Department of Health and Human Services, 1993) and the Essential Access Community Hospital/Rural Primary Care Hospital Program (Campion & Dickey, 1995). These programs were successful in demonstrating how states, working with rural communities and providers, developed networks of limited-service hospitals and other providers, increased the supply of practitioners, improved the financial position of rural hospitals, and fostered the integration of services to improve continuity of care and avoid duplication of care (National Rural Health Resource Center, n.d.). More than 50% of all ED visits to critical access hospitals were categorized as low-acuity cases, according to one study (iVantage Health Analytics, Inc., 2012). However, the average transfer rate of 4.0% for critical access hospital EDs is significantly higher than the 1.5% overall transfer rate reported by the Centers for Disease Control and Prevention (n.d.) and noted earlier (iVantage Health Analytics, Inc., 2012). These findings show that nurses who work in rural hospitals need to have the necessary expertise and skills to manage the trajectory of care from the ED to acute care, including stabilizing patients and preparing them for transfer to tertiary care hospitals.

The skills, knowledge, and expertise of emergency nurses in these settings is critical to the identification and stabilization of patients who require a higher level of care to promote safe, effective, and efficient patient care. It is important to understand the factors and interventions that facilitate or challenge high-level nursing expertise. Bushy and Bushy (2001) suggested that access to continuing education is critical to the maintenance and improvement of these skills, and education in these settings requires ingenuity and flexibility.

To identify and address the gaps in the educational needs of emergency nurses working in rural hospitals, including critical access hospitals, a two-phase study was implemented in 2012. The first phase of the study, reported here, was undertaken to understand more fully the educational needs of these nurses and identify potentially effective educational methods. For phase 1, the research question was as follows: What are the specific educational needs of emergency nurses in rural and critical access hospitals?

Phase 2 of the study will use data from phase 1 to develop and evaluate useful and cost-effective educational programs for nurses in these rural settings. The effect of these educational interventions on nursing knowledge and patient outcomes will be evaluated.

Methods

Sample, Setting, and Recruitment

A qualitative descriptive study design was used for phase 1 of the study. Institutional review board approval was obtained before study participants were recruited. Three focus groups were held in San Diego, California, during the Emergency Nurses Association Annual Conference in September 2012. A focus group format was chosen because it offered the opportunity to bring together a group of nurses working in these settings and allowed for uninterrupted discussion of the issues affecting this practice community. The homogeneous convenience sample of participants was recruited from a list of registered conference attendees. Those who participated in the study were registered nurses who were 18 years or older, worked in the ED of a rural hospital or critical access hospital, and had attended the 2012 Emergency Nurses Association Annual Conference in San Diego, California. Recruitment strategies included an e-mail that was sent to conference attendees who had preselected themselves to attend one of the focus groups. Additionally, a recruitment announcement for the focus groups was posted on the Emergency Nurses Association website to recruit eligible nurses who may not have received the e-mail. Participants were given an informed consent document that explained the study before the focus group was held. Participants were not provided with any form of compensation. At the focus group, each participant gave verbal assent. Nurses participated in only one of the three focus groups. Nurses who participated in the first phase of the study will also be given an opportunity to participate in the second phase.

Data Collection

Focus group data were used to identify content needs as well as barriers to education and factors facilitating education for emergency nurses working in rural and critical access hospital settings. A semistructured interview format was used to answer the following questions:
  1. What are the educational content needs of these nurses?

  2. What are the barriers to participation in educational activities?

  3. What factors facilitate participation in educational activities?

The focus group sessions lasted 1 hour to allow for a full investigation of the question without undue fatigue (Crabtree & Miller, 1999). The focus group was facilitated by a moderator. A second researcher took field notes and audiotaped the focus group. All focus group discussions were transcribed in their entirety. The transcribed data were analyzed by the principal investigator and members of the research team individually to identify common themes. The researchers analyzed the data a second time as a team to determine categories and themes.

Findings

Demographics

The sample (N = 33) was overwhelmingly female (84.8%) and 45 to 64 years (66.6%), reflecting average ages and gender of nurses nationwide (Table 1). More than half (56.7%) of participants held a bachelor’s or master’s degree, and 42.3% held an associate’s degree or diploma in nursing. Participants came from 23 geographically diverse states (Arizona, California, Colorado, Idaho, Illinois, Indiana, Iowa, Maine, Maryland, Michigan, Missouri, Montana, Nebraska, New Hampshire, New York, Ohio, Oklahoma, Oregon, South Carolina, Washington, West Virginia, Wisconsin, and Wyoming) and Canada. Most of the participants (90.0%) worked in a general ED; 63.3% worked in a designated critical access hospital, and 36.7% identified their workplace as “rural.” Similarly, most of the participants (63.3%) reported that their ED saw fewer than 30,000 visits per year (Table 2).

Participant Demographics (N = 33)

Table 1: Participant Demographics (N = 33)

Hospital Demographics (N = 33)

Table 2: Hospital Demographics (N = 33)

Based on the three questions that participants were asked about educational content, facilitators, and barriers, two themes emerged: (1) health disparities in rural and critical access hospitals and (2) recruitment and retention in rural and critical access hospitals. Under health disparities, three categories were described: personnel, clinical care, and resources.

Health Disparities in Rural and Critical Access Hospitals

Personnel. Participants described the variable skill levels of physicians as a particular challenge. Some participants reported that physicians in their ED were locums (travelers), with varying degrees of skill, or agency physicians who were trained in other specialties and did not have training in emergency medicine. Participants reported that physicians could also be employed in their ED without being board certified. Others reported that their ED had no physicians at all and employed only physician assistants. Participants noted that the absence of board-certified emergency physicians was distressing and frustrating. In addition, it challenged the nurses’ ability to clinically problem-solve both as individuals and as team members.

Participants also reported variable skill levels of registered nurses. Several participants reported that they did not have a dedicated ED nursing staff. In some cases, the hospital was so small that nurses were often “general,” meaning that they could be deployed to any unit that needed staff. Participants found this situation challenging because it limited their ability to obtain the necessary education or experience to perform emergency nursing well.

Clinical Care. An additional challenge to providing excellent care was a lack of knowledge of specific patient populations, such as critically ill, obese, pediatric, and obstetric patients, in addition to those with behavioral health issues and those with traumatic injury. This situation was especially problematic when these patients needed to be transferred to a higher level of care. Transfer could be delayed because of factors such as weather or availability of transportation vehicles. Participants also described the difficulty of preparing for “low-volume, high-stakes” situations. Specifically, they described patients who arrived with special devices and those who had recently undergone new types of surgical procedures.

Resources. Consistently, participants described a lack of adequate equipment, personnel, and educational opportunities in the practice environment. Nurses described a sense that outside educators from “big” hospitals did not understand the lack of resources at critical access and rural hospitals. For example, in discussing a need to learn more about ventilators for patients in respiratory failure, nurses described an environment in which the entire hospital had one or two ventilators and no respiratory therapist.

Participants also reported low staffing, sometimes with only one nurse in the ED without assistive personnel, such as technicians. Thus, a patient in cardiorespiratory arrest or even a “high-need” patient, such as a patient with sepsis or a behavioral crisis, can quickly overwhelm departmental resources.

Participants reported a lack of educational opportunities both within and outside of their institutions. They also noted that often no educator was on-site or the educator did not have specific preparation as an educator or as an emergency nurse.

Recruitment and Retention in Rural and Critical Access Hospitals

Effective retention strategies promote involvement (i.e., nurses are part of and are invested in the health care community in which they are located) and can improve the quality of health care and patient outcomes in rural areas. A framework of “attractiveness” can be used to recruit health care workers in rural locations (Dolea, Stormont, & Braichet, 2010). Interventions that can make facilities “attractive” and prolong health care workers’ engagement in rural areas include educational exposure, clinical rotations in rural areas, recruitment of health care personnel from rural areas (who then tend to stay there), and various types of educational and financial support. A review of the literature informing the current study concluded that more nursing research is needed in this area because most of the studies have focused on medical students and graduates.

As reported more than 10 years ago, significant problems in rural areas include the recruitment, retention, and education of health professionals (Bushy & Bushy, 2001). Fifty-two percent of rural hospitals reported that they had vacancies ranging from one or more part-time to three full-time nursing positions. Participants reported that this gap was filled with temporary nursing staff (“travelers”) and physician staff (“locums”) whose skill levels were variable and who presented a potential challenge to unit functioning. Participants described the temporary staffing in some critical access hospitals as a barrier to a well-educated, cohesive nursing team.

Discussion

Barnason and Morris (2011) reported disparities in care in rural and critical access hospitals, including lower rates of success with core measures of adherence to evidence-based practice guidelines for acute myocardial infarction, heart failure, pneumonia, and prevention of surgical infection. They also reported a lack of mental health services. The authors posit that, in part, these disparities are secondary to discomfort with performing interventions in emergency situations, specifically, neonatal emergencies. Participants also reported that general hospital staff were floated to the ED to provide care. In contrast, non-critical access hospitals had dedicated ED staff. These findings are in agreement with the comments of participants, who reported inconsistency of staff and lack of educational resources.

According to the literature, the most frequent medical problems treated in the ED of critical access hospitals were, in rank order, trauma (both minor and major), uncontrolled pain, acute episodic illness, chest pain, and mental illness (Barnason & Morris, 2011). Given the reported lack of comfort with emergency procedures and lack of mental health services, disparities in rural health care settings may be significant. Participants similarly reported both lack of experience and discomfort with certain groups of patients. These groups included mental health patients, pediatric patients, those who have undergone bariatric surgery, and those with traumatic injury.

Educational Needs

Hutchinson and Johnston (2004) identified barriers to the use of research, including lack of time, lack of confidence in critical appraisal skills, lack of authority, organizational infrastructure, lack of support, lack of access, and lack of evidence. Organizational infrastructure as a barrier can mean that the organization does not structurally support research (i.e., no dedicated trained staff, limited or no access to journal databases, and lack of organizational support for research in terms of time, personnel, or both. Lenz and Barnard (2009) also reported that nurses in rural hospitals do not report participation in evidence-based practice, probably because of lack of exposure. Recommendations for increased interest and expertise in research included additional ongoing learning opportunities, expectations set by leadership and leadership modeling, and support for collaboration outside the hospital with nurses who have research expertise. They cited a clear need for accessible continuing education in both content and research appraisal.

Educational barriers reported by the participants included long travel times, the expense of an overnight stay, and the difficulty of sending staff for more than a day without affecting staffing levels. On-site educators, when present, tend to focus on the mandatory education required by regulatory agencies and have little time for more advanced staff education.

The literature notes that entry-level education and distances traveled appeared to be major barriers to obtaining more education. A survey of nurse executives in rural hospitals found that nurses needed to travel an average of 43 miles for education and that the average nurse in a rural hospital holds an associate’s degree (Newhouse, Morlock, Pronovost, & Sproat, 2011). The authors suggested that a high level of critical thinking is required at a hospital with limited resources and that more accessible education is needed for nurses at these hospitals. Similarly, an Australian study (Paliadelis, Parmenter, Parker, Giles, & Higgins, 2012) found that professional development was identified as an unmet need for nurses in rural and remote areas. Again, this was because of the level of critical thinking required by nurses in the context of few resources and the need to travel long distances for educational opportunities. These issues must be addressed to mitigate problems of time, travel, and cost in phase 2 of this study.

Implications

The clinical knowledge base and critical application skills of emergency nurses working in rural settings and critical access hospitals are fundamental to ensuring safe patient care. Thus, the findings of this study have important implications for maintaining clinical competence and current clinical knowledge in this population. The phase 1 (focus group) findings are similar to those reported in the literature, showing important educational needs and suggesting that an accessible, effective, and economical system for delivering education should be developed. Participants generally agreed that short, “need-to-know,” focused videos to address the stated knowledge and practice gaps should be developed and delivered online to facilitate continuing education by addressing practice, economic, and access barriers.

This study was conducted to gain a better understanding of the educational needs of emergency nurses working in rural or critical access hospitals. Given the needs of this educationally isolated practice community, phase 2 of this study will be conducted to design and implement educational resources based on these findings and examine their effect on nursing knowledge and patient outcomes.

Limitations

Limitations of this study include the use of a self-selecting sample and a focus group format that may have influenced participants’ answers. Therefore, the study findings may not be generalizable to all emergency nurses who work in rural or critical access hospitals. However, the geographic diversity of the states represented by the participants may have reduced these limitations because nursing practice and educational requirements are dictated in part by state nursing board laws and hospital policy.

References

  • Balanced Budget Act of 1997, Pub. L. No. 105-33, § 4201, 111 Stat. 369 (1997).
  • Barnason, S. & Morris, K. (2011). Health care in rural hospitals: A role for nurse practitioners. Advanced Emergency Nursing Journal, 33(2), 145–154. doi:10.1097/TME.0b013e318217c96f [CrossRef]
  • Bushy, A. & Bushy, A. (2001). Critical access hospitals: Rural nursing issues. Journal of Nursing Administration, 31(6), 301–310. doi:10.1097/00005110-200106000-00008 [CrossRef]
  • Campion, D. M. & Dickey, D. F. (1995). Lessons from the Essential Access Community Hospital Program for rural health network development. Journal of Rural Health, 11(1), 32–39. doi:10.1111/j.1748-0361.1995.tb00394.x [CrossRef]
  • Centers for Disease Control and Prevention. (n.d.). National Hospital Ambulatory Medical Care Survey: 2010 Emergency department summary tables. Retrieved from www.cdc.gov/nchs/data/ahcd/nhamcs_emergency/2010_ed_web_tables.pdf
  • Crabtree, B. F. & Miller, W. L. (1999). Doing qualitative research (2nd ed.). Thousand Oaks, CA: Sage.
  • Dolea, C., Stormont, L. & Braichet, J. M. (2010). Evaluated strategies to increase attraction and retention of health workers in remote and rural areas. Bulletin of the World Health Organization, 88(5), 379–385. doi:10.2471/BLT.09.070607 [CrossRef]
  • Hutchinson, A. M. & Johnston, L. (2004). Bridging the divide: A survey of nurses’ opinions regarding barriers to, and facilitators of, research utilization in the practice setting. Journal of Clinical Nursing, 13(3), 304–315. doi:10.1046/j.1365-2702.2003.00865.x [CrossRef]
  • iVantage Health Analytics, Inc. (2012). 2011 National rural emergency department study: Establishing rural relevant benchmarks. Retrieved from www.ivantagehealth.com/wp-content/uploads/2012/02/2011-National-Rural-Emergency-Department-Study.pdf
  • Lenz, B. K. & Barnard, P. (2009). Advancing evidence-based practice in rural nursing. Journal for Nurses in Staff Development, 25(1), E14–E19. doi:10.1097/NND.0b013e318194b6d0 [CrossRef]
  • National Rural Health Resource Center. (n.d.). Flex program. Retrieved from www.ruralcenter.org/tasc/flex
  • Newhouse, R. P., Morlock, L., Pronovost, P. & Sproat, S. B. (2011). Rural hospital nursing: Results of a national survey of nurse executives. Journal of Nursing Administration, 41(3), 129–137. doi:10.1097/NNA.0b013e31820c7212 [CrossRef]
  • Paliadelis, P. S., Parmenter, G., Parker, V., Giles, M. & Higgins, I. (2012). The challenges confronting clinicians in rural acute care settings: A participatory research project. Rural and Remote Health. Retrieved from www.rrh.org.au/articles/subviewnew.asp?ArticleID=2017
  • U.S. Department of Health and Human Services. (1993). Medical assistance facilities: A demonstration program to provide access to health care in frontier communities. Retrieved from https://oig.hhs.gov/oei/reports/oei-04-92-00731.pdf

Participant Demographics (N = 33)

Characteristic n %a
Age (years)
  25 to 34 2 6.1
  35 to 44 5 15.2
  45 to 54 11 33.3
  55 to 64 11 33.3
  ⩾ 65 4 12.1
Level of nursing education
  Diploma 4 12.3
  Associate’s degree 9 30.0
  Bachelor’s degree 12 40.0
  Master’s degree 5 16.7

Hospital Demographics (N = 33)

Characteristic n %
Emergency department patient population
  General (adult and pediatric patients) 27 90.0
  Adult only 2 6.7
  Pediatric only 1 3.3
Annual emergency department patient visits
  1 to 5,000 3 10.0
  5,001 to 10,000 7 23.3
  10,001 to 20,000 6 20.0
  20,001 to 30,000 3 10.0
  30,001 to 40,000 4 13.3
  40,001 to 50,000 3 10.0
  50,001 to 75,000 1 3.3
  75,001 to 100,000 1 3.3
  Do not know 2 6.7

Key Points

Emergency Nurses

Wolf, L. & Delao, A. M. (2013). Identifying the Educational Needs of Emergency Nurses in Rural and Critical Access Hospitals. The Journal of Continuing Education in Nursing, 44(9), 424–428.

  1. Emergency nurses who work in rural hospital settings face unique challenges in the required breadth and depth of skills needed to recognize, stabilize, and transfer patients who require a higher level of care.

  2. Access to continuing education for emergency nurses who work in rural hospital settings is critical.

  3. Developing and delivering continuing education to this significantly isolated practice community is vital to safe patient care.

10.3928/00220124-20130816-38

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