Rural nursing practice is an integral component of the health and well-being of the communities they serve (Shields & Tremblay, 2002). Invariably, the majority of health services in rural communities are provided by nurses (Jackman, Myrick, & Yonge, 2012). In fact, in some rural and many remote areas, the RN is the only primary health care provider. Canadians who reside in these rural and remote communities are reportedly less healthy, experiencing shorter life expectancy and higher rates of smoking, obesity, substance abuse, and mental health conditions (Dowdle-Simmons, 2013). Moreover, the socioeconomic status of these Canadians has been found to be lower than among their urban counterparts (Dowdle-Simmons, 2013). Hence, rural researchers assert that the educational preparation of rural nurses who are able to recognize and address the unique needs of rural communities is urgently required (Sedgwick & Yonge, 2008). However, to date, it is uncertain which strategies are most effective in preparing nursing students for the diversity of rural practice.
Although the focus of this article addresses one aspect of the findings of the larger study vis-à-vis community spirit, cultural connections, and authentic learning rural preceptorship, the purpose of the overall study was to examine the challenges and opportunities of rural, undergraduate nursing preceptorship as experienced by senior nursing students and the faculty advisors and preceptors who support their learning (Oosterbroek, 2017). Failure to adequately prepare nurses for the complexity of rural nursing has resulted in low job satisfaction and morale as well as high staff turnover (Forbes & Edge, 2009), specifically where recruitment and retention of nurses in rural and remote areas is an ongoing challenge (Hanson-Smith, 2012). High staff attrition rates can be detrimental to the health of rural residents when caregivers who are knowledgeable and invested in the health of the rural community are transient. Hence, educational strategies aimed at preparing nurses to work and stay in rural communities is crucial (Oosterbroek, 2017).
Preceptorship provides a vehicle through which the student becomes immersed in the rural setting over a long-term period (Oosterbroek, 2017; Sedgwick & Yonge, 2008). In Canada, senior nursing students are assigned one-to-one with an experienced RN for a period of approximately 10 weeks. Throughout the preceptorship, the nursing student works side-by-side with the RN, gradually assuming the roles and responsibilities of the RN while receiving continual guidance and feedback. Rural preceptorship requires sustained engagement and collaboration between the nursing student and community members, including patients, families, and other health care providers, which creates an optimal environment for authentic learning.
Culture refers to a set a values, beliefs, and practices that are dynamically interwoven with “historical, economic, political, gender, religious, psychological, and biological conditions” (College & Association of Registered Nurses of Alberta, 2013, p. 24) that ground and guide individuals, and include traditions and ceremonies that reflect and honor cultural diversity. Cultural safety in nursing is both a process and an outcome of intentional interaction between the nurse and the client, requiring commitment by the nurse to recognize, respect, and value individuality and diversity among all individuals. Subsequently, the power imbalances that are inherent in health service delivery need to be addressed by the nurse in ways that “foster the cultural expression of clients.” This approach thus requires nurses to reflect critically on issues of racialization, institutionalized discrimination, culturalism, and health (College & Association of Registered Nurses of Alberta, 2013, p. 24). National and provincial regulatory bodies in Canada have declared cultural safety as a fundamental entry to practice competence for RNs (Canadian Nurses Association, 2010; College & Association of Registered Nurses of Alberta, 2013). This requisite reflects the purpose of trans-cultural theories of ethical nursing care: seeking to understand each other by seeing, hearing, and learning together from a moral ethic of caring (Ray, 2010). Historically, the sharing of traditional knowledge, values, and beliefs specific to distinct social groups in rural communities has been lacking from the health curricula (Shields & Tremblay, 2002).
Nursing students who are immersed in an environment that recognizes and appreciates the impact of contextual factors on learning outcomes results in an authentic learning experience (Forbes & Edge, 2009; Sedgwick & Yonge, 2008). An authentic learning environment fosters socialization of the nursing student to a particular community context and unique culture of the individuals who reside in that culture. The final preceptorship provides an extended clinical practice experience allowing for this immersion while providing consolidation of learning as preparation to enter practice.
Insofar as community spirit is a central element of rural life, successful teamwork is the key to successful rural preceptorship (Sedgwick & Rougeau, 2010). Students must learn to navigate the close-knit work culture of the rural community; this experience may serve as a point of tension that could inhibit a student's ability to learn. However, such tension tends to diminish once the student achieves a sense of belonging. Meyer Bratt, Baernholdt, and Pruszynski (2014) further affirmed the connection of belonging to the community with job satisfaction and the intention to seek employment upon completion of the nursing placement. Adding to the complexity of the preceptorship, professional relationships and boundary issues have been reported by students who have lived and worked in the same community (Pront, Kelton, Munt, & Hutto, 2013; Yonge, 2009).
Cultural practices unique to each rural community represent the spirit of the community. Indeed, cultural practices, traditions, symbols, and rituals serve to characterize the spirit of the community (Ray, 2010). Yonge, Myrick, Ferguson, and Grundy (2013) explored the significance of the physical landscape as representative of the culture of the rural community. These researchers found that rural identity informs student and preceptor perceptions of the spirit of the rural setting. They also found that the rural landscape both influences and reflects the determinants of health, such as time, space, and physical and environmental resources. Space and distance were key among these, directly influencing the time required for rural residents and health care providers to travel to access local services such as schools and health services. The photographic research data revealed everyday factors that influenced access to services, such as seasonal weather patterns, local infrastructure, and safety concerns related to poor road conditions and repair. Also apparent was the juxtaposition of traditional and modern influences in rural communities; historical sites and buildings reflecting the spirit of the rural community, alongside modern facilities, represented how rural communities advance while maintaining their connection to the past (Oosterbroek, 2017). These images may signify community members' conflicting feelings of loss and gain as their past is replaced by modern, new, and ostensibly superior facilities.
Nursing inquiry has been described as a political activity requiring moral engagement of the researcher with participants (Meleis, 1997). Given that medical and nursing research throughout history has been strongly influenced by positivism, nurse researchers must be cognizant of the complex relationships existing among gender, race, culture, power, and socio-political factors (Anderson et al., 2003; Holmes, Bernard, & Perron, 2008). Most influential to the advancement of knowledge in the social sciences can be attributed to postmodernism. This time period reflects the influence of philosophers such as Lyotard and, most notably, Foucault. Lyotard (1979) was skeptical of the metanarrative as an overarching way of constructing knowledge, explaining, and understanding the world around us that represents the complex sociopolitical intersection between historical discourse and power. Foucault, the most notable of postmodernists, viewed knowledge as a product of societal power relationships (Anderson & McCann, 2002; Meleis, 1997). He rejected global totalitarian theories that did not recognize the influence of power imbalances in knowledge development. Foucault challenged the norms, suggesting new ways to critique the relationship between knowledge, truth, and power (Martin, as cited in Diamon & Quinby, 1988). The postcolonial approach is one of three approaches that emerged from the postmodern era. Knowledge developed in nursing is influenced by the uniqueness of the approach the theorist applies to the process. The postcolonial perspective extends the way we actually perceive and address issues related to culture by accounting for contextual historical and sociopolitical factors (Racine & Petrucka, 2011) in a transformative way that differs from postmodern and poststructuralist views (Meleis, 1997).
Participatory action research (PAR) emerged from the research activities of postcolonial and feminist scholars who rejected traditional methods of knowledge development and inquiry (Gubrium & Harper, 2013) that were focused on the goals and priorities of the researcher. PAR methodologies materialized to address issues of power inequality and oppression that exist in the traditional researcher–participant relationship. Collaborative determination of goals is paramount in PAR, allowing participants to determine what is important and what requires change. Ensuring congruence between the philosophical underpinnings and methodological operationalization of research activities is crucial when knowledge translation at the community level is a priority. Significant and meaningful connection with community members is essential not only to engage community member participation but also to improve effective knowledge transfer at the community level. PhotoVoice has been used as an instrument of data collection to enhance knowledge transfer among marginalized groups. Racine and Petrucka (2011), for example, used PhotoVoice to engage Aboriginal community members in the research process in a meaningful way. Further, PhotoVoice is not only congruent with the epistemological and ontological assumptions of postcolonial feminism, but it is also an effective method for engaging communities that appreciate and respect visual representations of their stories (Racine & Petrucka, 2011) and thus was implemented for the purposes of this study. Remaining true to these philosophical values concerning knowledge development, the following assumptions underlie the study:
- Rural communities are entrenched in an historical and traditional context that influences their overall social climate and culture.
- Enhanced understanding of the challenges and opportunities inherent in rural practice serves to enable nursing students to build competence and learn skills required to meet the unique health needs of rural residents.
- The experiences of students, preceptors, and faculty advisors during undergraduate rural nursing preceptorships will provide insights essential to the recruitment and retention of recent graduates, who may be committed to long-term employment and social investment in the community.
In keeping with this study, each participant was provided an inexpensive automatic camera and memory card. Participants were instructed to capture uncensored images frequently throughout the preceptorship that, in turn, illustrated challenges or opportunities of rural practice.
Rurality remains an elusive concept, defying definition. Rurality has been described a sense of place and way of life, associated with living in a rural community (Balfour, Mitchell, & Molestane, 2008). In this study, rural is defined as any community with a population of fewer than 50,000 residents, at least 20 km from the nearest urban community (Kulig et al., 2008). True to this definition, the study took place in several rural communities, in the south and central regions of a western Canadian province.
The nonprobable, purposive sample comprised fourth-year nursing students (n = 9) and faculty advisors (n = 5) from two baccalaureate nursing programs in Western Canada, assigned to rural communities for their preceptorship placements. Despite recruitment strategies, preceptors declined to participate in the study.
Ethical approval was granted by the Research Ethics Office at the researchers' academic institution. Criteria of the Tri-Council Guidelines for Human Subjects Research were followed.
Data Collection and Analysis
Data collection and analysis were conducted concurrently in four phases throughout the academic semester. The researcher conducted individual, face-to-face interviews twice during the preceptorship. Each interview was audiorecorded and transcribed by the researcher. In keeping with the principles of PAR, each participant self-selected images to represent the challenges and opportunities they encountered. These images stimulated conversations during one-to-one interviews between the participants and the researcher. Using the processes described by Braun and Clark (2006), thematic data analysis was conducted, beginning on commencement of data collection. This process allowed for emergence of themes or patterns from the data.
Findings and Discussion
Reflecting prior studies, rurality was described by these participants as more than a geographic location (Jackman, Myrick, & Yonge, 2010; Kulig et al., 2008; Kulig, Kilpatrick, Moffitt, & Zimmer, 2015) but rather as a sense of place and a way of being and doing that represented rural life. Rurality was depicted more specifically by participants in terms of community spirit and cultural contexts. The participants' depictions of rurality within the context of community spirit and cultural context were observed in various ways throughout the rural community. For the students who lived in the rural community during the preceptorship, this sense of community spirit extended beyond the health care setting.
Close-knit, community spirit is central to rural life (Sedgwick & Rougeau, 2010). Examining international immigration patterns, Krivokapic-Skoko and Collins (2016) found that community spirit is a natural attraction of rural communities. The participants photographed numerous symbolic representations of rural spirit: murals (Figure 1), sculptures, old farm equipment (Figure 2), and advertisements for local celebrations and locally owned restaurants (Figure 3). These images captured the unique cultural manifestations of each rural community, reflecting cultural practices, values, and beliefs of the community (Ray, 2010).
Participant photograph of a mural.
Participant photograph of an old tractor.
Participant photograph of a local restaurant.
Hannah (all names are pseudonyms) photographed an old tractor (Figure 2) that was embedded as part of the towns' landscape design. She thought the tractor represented a way of life that was “emblematic of the town and what's around it.”
She went on to say a great deal could be learned from observations made in the community, remarking, “it cues you to what kind of community you are going to be in, because if there are a lot of farmers; there might be challenges associated with that, or the types of patients you're going to see.”
Robert found that many immigrants had opened restaurants (Figure 3) in some of the rural communities he visited as part of his preceptorship placement. Robert suggested that this represented community engagement through support of the local restaurant. He found that the little eatery was a kind of rural attraction, “a really small…mom-and-pop kind of business, but one of the things that would make a small community more alive.” These remarks are consistent with the Yonge et al. (2013) findings that participants' photographs captured numerous symbolic representations of the community, with significant personal and historical meaning to its residents.
Daniel was struck by the degree of trust he observed both in the rural community and the health care site, photographing recently sterilized equipment and instruments dropped off at a designated spot in a common hallway (Figure 4). He was surprised that no one interfered with these items and that there had never been an incident of tampering, saying, “They know not to touch stuff like that—kind of like, in a rural place, everyone leaves their front door open,” he surmised. “I feel like it kind of symbolizes, that it's here for a reason; don't touch it.” The participants observed a sense of trust within the community and at the health care setting, among employees and visitors. Staff extended this trust to the nursing students, thereby creating a safe place for learning and asking questions.
Participant photograph of sterile equipment.
Previously, researchers have found that extended clinical placements in the rural communities enhanced student learning as they became immersed in the rural community and rural way of life (Meyer Bratt et al., 2014; Sedgwick & Rougeau, 2010; Webster et al., 2010). The sense of community these student participants experienced during their rural preceptorship was influential to their learning experience; enhancing their engagement with the health care community and rural community by and large and sense of belonging and connectedness to the community. This, in turn, resulted in an investment in the community and the health of its residents, thus motivating and inspiring the nursing students to achieve excellence in the provision of their nursing care and resulting in a successful preceptorship.
Although engaging and connecting with the community was replete with positive outcomes on learning and the rural preceptorship overall, this strong sense of community spirit that was distinctly rural presented unique challenges for the students. Personal and professional boundaries assumed a greater significance in these communities. Sarah (a faculty advisor) described being taken aback by “the effect on families you might have. People come up two years later and introduce me to the child I helped deliver…. It is very profound.” Stacey (a faculty advisor) recounted numerous situations wherein she was approached outside of work by community members with health-related inquiries, some of which she received by telephone or text message. James (a faculty advisor) emphasized challenges associated with communication in small rural communities, especially regarding maintaining patient confidentiality regarding family members or neighbors. In rural communities, he pointed out, it might appear that “ruralness [sic] supersedes health care…yet the students know they can't talk about patients.”
Some of the students encountered dilemmas related to anonymity and confidentiality, unknown to them in their urban rotations, evidenced by Beth's statement: “Working at the hospital, I see people that I've seen in the community and they are like where do I know you from, and I'm just a student.… Even going to the gym, people recognize me from the hospital.” Jenn found that her professionalism was constantly being tested. “I kind of like the anonymity of being in the city and not having people know who I am,” she admitted. “Here, everyone knows each other's business, for better or worse…. People [in the community] will ask about patients at the hospital, and you can't say anything. You know they are there, but you can't tell them anything.” Even over the course of a 10-week preceptorship, the students confronted some of the anonymity and confidentiality issues of rural nursing. Ava discovered that patients well known to hospital staff might even encounter prejudice: “I guess there is room for bias, if you remember everyone so closely and know their situation(s),” she surmised. “For example, a mom that comes in, and you've delivered her first eight kids, and they've all been apprehended…you might be a little more worried about this next one.”
Duality of roles can be challenging for experienced nurses who experience the dichotomy of feelings from these interactions that vary from pride to professional detachment (Yonge, Myrick, Ferguson, & Grundy, 2015). Although the blurring of personal and professional roles in the community betokens the tremendous respect accorded to nurses by community members, it can be stressful for nursing students nonetheless as they learn to navigate and balance these conflicting expectations (Yonge et al., 2018; Yonge et al., 2015). Insight regarding factors that may influence the student experience in the rural setting may be enhanced by the faculty members' familiarity with the rural community (Little, Stokes-Parish, Hawkins, & Collier, 2017). Sarah (a faculty advisor) lives and works in a rural community, where she supervises students in preceptorship. She was mindful of preparing nursing students for the challenges of working in small close-knit rural communities, suggesting they should be oriented to the community as a whole, not just the health care setting. “[Have them] go look through the town to discover…churches…[and] services,” she said, by way of example; “help them to see the prettiness, not just the bareness.” Sarah took her students to the “good” restaurant in town to introduce them to community members, whom she knew well. She believed this approach prepared the students for the reality of rural work, where everyone in the community would know their names and approach them outside work hours, seeking advice. Awareness of potential boundary issues prepares students to respond professionally as they adjust to a different way of life, unique to each rural community. “Being asked about patients by community members; family members; even staff members; people working in different parts of the hospital—what do you do?” mused James, a faculty advisor. “Students are burdened with that, so if they're not prepared for those types of situations, that could be a challenge.” Boundary issues are further complicated by the social needs of older adults living in rural settings, who value and seek out personal connectedness (Corbett & Williams, 2014).
Rural communities are steeped in tradition and cultural symbolism. Figure 5 exemplifies the juxtaposition of the rural versus urban themes that emerged from the findings representing the dichotomy of urban–rural life and capturing an example of cultural identities that are uniquely prominent in many rural communities.
Participant photograph depicting rural versus urban.
Several participants discussed the cultural context of the rural communities. Becky described how her exposure to cultural groups in rural communities differed from her prior experiences: “In the city, you have more diverse ethnicities, but out here it is pretty much…one major culture.” She was struck by the signage and documents at the hospital, almost all of which were bilingual in English and Cree (Figure 6). To Becky, this was a “symbolic representation” of the unique culture of the community, meaningful to community members, and also an opportunity for learning. She stated, “[Students] need to get in touch with what community is like…. We are close to the reserve. We get a lot of reserve residents, but I think if you were near a [Hutterite] colony, you would get more Hutterites.… It is important to know…certain cultures, related to respect, and how you talk to them. You should be aware of that.” Becky and her classmates grew to understand the diverse cultural groups residing in rural communities and the need to be cognizant of their unique health care profiles.
Participant photograph of a Cree sign.
In describing rural preceptorship, James (a faculty advisor) drew a parallel between rural work and rural life, citing the “potential for increased learning, through immersion in the culture. You are out there; you're in it…. You have to use all your knowledge to make things work. And that is kind of related to rural life too, right?” One must learn not only about distinct cultural groups who reside in the community, he pointed out, but also be cognizant of the health care workplace culture; key staff members therefore acted as gatekeepers, facilitating students' assimilation into this culture.
Stacey (a faculty advisor) described the importance of recognizing and investing in the cultural context of the community. She shared an image of the entrance to one of the health care settings that was written in Cree and English (Figure 7).
Participant photograph of an entrance sign.
This is a picture of their “enter” sign to show that they work in two different languages. For cultural diversity and cultural sensitivity teaching, we have an elder come out and speak to our students and he actually teaches them some Cree. Some basic words that might actually help you to build that relationship. A lot of the home care patients that students go and see are quite elderly and they appreciate if you try to speak their language. It just shows that you are a little more invested in them as a person and not just seeing them for their wound or their ailment that they have at the time.
Strengths and Limitations
The study contributes to the state of knowledge around the opportunities and challenges experienced by nursing students and faculty advisors during undergraduate nursing preceptorship in rural settings. Use of PhotoVoice as the method for data collection provided the participants with the freedom to capture images of sights and experiences that were most meaningful to them and most clearly and accurately represented their rural preceptorship experience. Upon reflection on their selected images, both students and faculty advisors came to appreciate the opportunities that arose from what initially presented as a challenge.
The primary limitation of the study was the lack of preceptor participants, limiting the findings to the experiences of opportunities and challenges from the perspective of students and faculty advisors. The perspective of nursing preceptors during preceptorship, in particular during rural preceptorship, remains a gap in the current literature and warrants examination. Barriers to participation in research among rural RNs requires more clear understanding. Strategies or incentives to improve recruitment of rural RNs in research are critical to address barriers to participation.
Conclusions and Recommendations
Students who successfully navigate the close-knit, rural practice community experience are empowered by a sense of belonging that enhances their learning throughout their preceptorship. Rural communities are commonly home to complex populations encompassing diverse religious, ethnic, cultural, and multigenerational families (Crow, Conger, & Knoki-Wilson, 2011; Lake Morgan & Reel, 2003). These participants described how the rural preceptorship contributed to a greater understanding, appreciation, and respect for cultural diversity that grew alongside their relationships with the community members for whom they cared. Their images captured the unique nature of the rural community and reflect the local culture and community spirit that represent the essence of the community. This reflects the congruence between the research method and the unique nature of the research setting. By employing a postcolonial framework, the research participants gave voice to the unique way of being of each rural community. The photographs were unique to each community, eliciting rich descriptions of its characteristics. These images also evoked scenarios the students witnessed in the hospitals, such as farming and highway traffic accidents. Such instances exemplified patient concerns that are common in rural health care.
Rurality remains an elusive concept, difficult to define. Nevertheless, the participants' photographs and comments captured the sense of community spirit, patterns, habits of communication, and cultural contexts that comprised the distinct nature of each rural community to which they were assigned. Significant and meaningful connection with community members is essential, not only to engage community member participation but to improve effective knowledge transfer at the community level. PhotoVoice has been used as a method of data collection to enhance knowledge transfer among marginalized groups. Within the context of this study, PhotoVoice is not only congruent with the epistemological and ontological assumptions of postcolonial feminism, but it also was an effective method for engaging participants and representing the unique nature of rural nursing preceptorship. This form of inquiry places the voice of the individual or community at the forefront, thus producing knowledge that represents their unique needs and experiences (Racine, 2003).
More research about rural health is needed to understand the cultural and contextual factors that uniquely affect the health status of rural Canadians. Adequate preparation of future nurses who work in rural and remote communities is essential to ensure access to safe, competent, and culturally aware nursing care. Rural practice placements have the potential to enrich undergraduate nursing education and to expose undergraduate nursing students to the role of the rural nurse. This role is unique in that it affords meaningful connections with the rural community at large, through identifying and responding to specific cultural and community needs. Students are encouraged to learn with and from each other by active engagement with peers, preceptors, and interprofessional team members. Although the purpose of this study was not intended to examine undergraduate nursing students' desire to seek employment in rural communities, successful rural nursing preceptorships introduce future nurses to the challenges and opportunities of rural practice and may encourage recent graduates to seek out permanent employment in rural settings.
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