The 1990s and Beyond: Determining the Need for Community Health and Primary Care Nurses for Rural Populations*

Increased numbers of primary care and advanced practice nurses with unique generalist skills will be required to meet the accelerating physiologic and sociocultural health care needs of rural populations. Several factors have been identified that will influence the demands and position of community-based nurses in rural practice settings during the next decade. A back-to-basics type of health care offered out of a growing elderly population; technological breakthroughs that make it possible for more chronically ill patients to live at home; serious substance abuse and other adolescent problems; AIDS; and high infant morbidity and mortality statistics are only some of the concerns that will demand nursing intervention. These changes speak to the need for improved nursing coordination, stronger collegial relationships, and better communication between physicians and nurses. Health care is moving in new directions to offer more efficient and technologically sophisticated care. These changes enhance the need for clinically expert educators who teach and jointly practice in programs with a rural focus. Telecommunications, and heightened computer literacy, will play a major role both in nursing education and clinical practice. The goals of kindergarten through 12th grade health promotion and disease prevention strategies in school health will be the norm and will require better prepared, and positions for, school nurses. More midwives and public health nurses will be needed to care for the growing population of sexually active adolescents who are in need of family planning and prenatal care. Underinsured and indigent populations will continue to fall within the purview of midlevel practitioners, as will providing anesthesia services in small rural hospitals. The transition of some rural hospitals into expanded primary care units (e.g., EACHs and RPCHs), and new models of case management will greatly influence nursing demands. This paper will further identify critical areas of advanced practice nursing within community settings, including new relationships with other health care providers, and will introduce strategies upon which rural health policy recommendations for the 1990s can be addressed.     

THE STATUS OF RURAL NURSING IN AUSTRALIA: A REVIEW

ABSTRACT: While much has been written about the practice roles of remote area nurses in Australia, less is known about the role and function of the rural nurse. The majority of rural nurses practise in rural hospitals, community health settings and nursing homes. In contrast, the remote area nurses work setting is generally involved with Aboriginal and Torres Strait Islander primary health care services. Rural nurses' practice setting is usually located in a larger organisation than that of the remote area nurse. There is usually at least one medical practitioner in the town or on-call close by. Nurses who are employed in the smaller rural hospitals have what has been described as a 'specialist generalist' role. This means that they are required to be multi-skilled and competent in a wide range of nursing and non-nursing practice. In contrast, nurses who work in base/provincial hospitals, may have either a generalist or specialist role. This paper provides a summary of the literature on Australian rural nurses and develops some of the themes contained therein.     

Redefinition of School Nursing Practice: Integrating the Developmentally Disabled

Results of three needs assessment studies which had the purpose of providing direction for school nursing practices which would address some of the unmet health needs of today's children and adolescents are reported. Results provide specific examples of how school nurses have not been meeting school health needs through an analysis of one specific need -- integrating the developmentally disabled into the regular school setting. Data were collected from parents, teachers and other supportive personnel in schools by interview and survey methods. Environmental assessments were conducted and the policies and procedures governing health-related activities required by special need students were reviewed. The data indicated that for developmentally disabled students, nurses were not performing the commonly accepted functions of nursing and were not transposing their knowledge of the components of health care ordinarily provided in health care settings to care provided in nontraditional health care settings. Examples of nursing functions and the activities needed to fulfill those functions are provided.     

International Perspective: RURAL NURSING IN THE UNITED STATES: WHERE DO WE STAND AS WE ENTER A NEW MILLENNIUM?

ABSTRACT: Approximately one-fourth of all Americans live in rural communities; and, of the 50 States, 31 have more than 60% of their counties designated as rural. No matter what indicator is used, United States residents in non-metropolitan areas have less than metropolitan counterparts (e.g. per capita income, health status, access to care, level of education and employment opportunities) and are more likely to need help from human services and health professionals. Additionally, rural people often must confront unique obstacles not experienced by most urban residents to access those services. As nurses live and work in rural communities they, too, must be aware of and contend with similar factors in their practice settings. In some ways rural nursing practice has changed dramatically over the last decade but in other ways things remain much the same. This article will examine common nursing issues associated with caring for clients in a rural environment. The information in this article is based on a review of the literature and the author's personal and professional nursing experiences.     

Health Services Utilization and Special Education: Development of a School Nurse Activity Tool

Increasing competition exists for resources to support health services for children receiving special education. Consequently, management tools to document services when claiming these resources need to be developed. The purposes of this study were to develop a time study instrument based on nursing activities in the school, compare nursing time provided to special education children and their nondisabled peers in general education settings, compare nursing process activities in traditional settings and in special education settings, and elicit feedback from nurses to improve the validity and reliability of the time study process. Eighteen nurses representing rural, urban, and suburban schools completed a time study for two weeks, quantifying services provided in the health room. Nurses recorded student educational status, special education category or not, nursing process activity, and the time utilized per student contact. Results indicated 48.2% of school nursing time was attributed to services for special education students during the study period. Most nursing process activities for both settings were in assessment of problems and in direct services. Findings indicate the instrument can provide objective documentation of special education health services, providing a base for claiming important resources for school health services.     

WORKING TOGETHER: THE ADVANCED RURAL NURSE PRACTITIONER AND THE RURAL DOCTOR

ABSTRACT: This paper discusses the complex and interrelated roles of the rural nurse and doctor. These roles are viewed as being complementary to each other in any healthcare setting, but more so within the context of rural Australia. The current move towards the development of advanced nurse practitioner roles is often clouded by unnecessary medical fears that nurses are attempting to displace doctors. In contrast, this paper argues that the development of new rural nursing roles identifies rural nursing as a major specialist area within the wider profession of nursing and, at the same time, recognises the reality of practice for many rural nurses. Individual public figures may perceive the solution to the shortage of rural doctors to lie in their replacement with nurses. The nursing profession, however, will resist this approach. Nursing is not the first rung on the ladder to a career in medicine. Nurses are educated and acknowledged to focus their practice on the clients' responses to healthcare problems and not the practice of medicine. The primary role of the nurse is to provide care. The primacy of care should not be set aside by those nurses seeking to develop their practice, nor should advanced practice be defined in terms of taking on tasks previously carried out by other healthcare professionals.     

Nurses' widespread job dissatisfaction, burnout, and frustration with health benefits signal problems for patient care

Job dissatisfaction among nurses contributes to costly labor disputes, turnover, and risk to patients. Examining survey data from 95,499 nurses, we found much higher job dissatisfaction and burnout among nurses who were directly caring for patients in hospitals and nursing homes than among nurses working in other jobs or settings, such as the pharmaceutical industry. Strikingly, nurses are particularly dissatisfied with their health benefits, which highlights the need for a benefits review to make nurses' benefits more comparable to those of other white-collar employees. Patient satisfaction levels are lower in hospitals with more nurses who are dissatisfied or burned out-a finding that signals problems with quality of care. Improving nurses' working conditions may improve both nurses' and patients' satisfaction as well as the quality of care.     

Nurses' perceptions of inter- and intra-professional relationships: an analysis of support from nursing and physician colleagues in rural hospitals.

Nurses employed in ten rural hospitals in Canada completed questionnaires designed to examine their perceptions of the strength of the professional relationship which existed among nurses and between nurses and physicians. Four questions addressed the availability of nursing education programs and the attendance of nurses and physicians at such programs. Seven questions examined the nurses' perception of physician interest in nursing education and the encouragement received from their nursing colleagues to participate in learning activities and medical management decision making. Chi square analysis was undertaken to determine whether the colleagial relationships differed by hospital or medical staff characteristics. Forty percent of the nurses felt that the majority of of physicians were supportive of continuing nursing education. Sixty-three percent indicated their nursing colleagues encouraged them to attend educational programs. The results indicate that physician participation in nursing continuing education was greatest in communities with the fewest health resources (an acute hospital with fewer than 50 beds). In contrast, encouragement to participate in continuing nursing education was highest in settings where the hospital provided both acute and extended care services, had more patient admissions and a greater availability of educational programming.     

A Logit Analysis of the Likelihood of Leaving Rural Settings for Registered Nurses

This study examined the net effects of individual and community factors on the likelihood of registered nurses leaving current jobs using a logit analysis. Based on data from a survey of 2,509 rural nurses, four separate models were estimated and compared: one for nurses in rural settings as a whole and the other three for nurses in hospitals, skilled nursing facilities, and community/public health agencies. Results of the general model indicated that nurses' marital status, age, position, income, job satisfaction, and satisfaction with the community were significant determinants of the likelihood of leaving current jobs. Job satisfaction was the most significant factor, followed by satisfaction with the community. Findings from the models for three different employment settings were similar to those of the general model. However, the significance of factors and their strength of effect on nurses' decisions to leave or stay in their current jobs differed across the three types of facilities. Based on these findings rural nursing administrators and policy-makers should give priority to retention strategies that focus on improving the job environment. The development of different strategies for different groups of nurses (i.e., by age or marital status) and different types of facilities should increase the benefit/cost ratio. In addition, programs that involve rural health care agencies in community and economic development should be further explored as an avenue to increased nurse retention in rural areas.     

新医改视域下北京市基层护士对失能失智老年照护的知信行现状与发展需求分析

目的 了解北京市基层护士对失能失智老年照护的知信行现状及发展需求,为改善基层医院失能失智老年照护策略及政府相关政策的提出提供实证依据.方法 采用自制《基层护士老年失能失智照护知信行及需求调查问卷》对北京市232名基层护士进行老年失能失智照护知识、行为、态度以及需求的调查.结果 北京市基层护士失能失智老年照护知信行总分为...     

Preparation of social workers for a changing health care environment

Rapid changes in health care have provided the impetus for social workers to reexamine their professional preparation for effective practice in health care settings today. Faculty teaching students and field instructors were asked to indicate on a questionnaire where specific subject matter is taught to social work students: in the classroom, in the field, or in both settings. Results of the study show a communication gap between school and field and a need for teaching models that enable educators to convey more of the profession's expanding knowledge base and to prepare students to deal with concurrent demands for expertise and expediency in practice. Programmatic changes to address these issues are suggested.     

The family and nurse in partnership: providing day-to-day care for rural cancer patients

OBJECTIVE: To explore demands made on family members in managing symptoms and providing for the day-to-day care of relatives with cancer in rural New South Wales and how specialist palliative care nurses support these family members. DESIGN: Cross sectional qualitative study. SETTING: Seven health centres across rural New South Wales that cover a broad geographical area and reflect the diversity in economic conditions, population density and distance from three major urban centres in New South Wales. SUBJECTS: The study involved two groups of participants. The first group consisted of one or more members of families of oncology patients who were accessed through health workers at the seven centres. Nineteen family members from 17 families were interviewed. The second group comprised 10 nursing staff working as specialist palliative care nurses across the same geographical area as the families. MAIN OUTCOME MEASURES: Physical care and symptom management were the two main areas of interest. RESULTS: The rural experience of caring for palliative care patients was challenging, with support nurses needing to take into consideration all aspects of the patients' and families' living environments. CONCLUSION: There is a need for equipment and basic resources to be readily available to practitioners, funding for ongoing education and 24-h care.     

Evaluating rural nurses for preparation in implementing nutrition interventions.

With the increase in wellness programs, earlier hospital discharges, higher health care costs, and more home health care, rural nurses are required to generalize their practices and draw from a more extensive knowledge base. The purpose of this study was to examine nursing interventions, specifically nutrition education practices, based on nutrition knowledge that is used in health promotion. A stratified random sample of rural nurses from hospitals, nursing homes, and community health agencies in North Dakota was invited to participate in this study. Data were obtained via questionnaires. The questionnaire consisted of two parts: the first analyzing demographic data and the second analyzing nutrition knowledge. Nutrition information requests were received by 90.9 percent of the practicing registered nurses. The community/public health nurses had the highest nutrition knowledge scores while medical-surgical hospital nurses had the lowest nutrition knowledge scores. With nutrition information and education being a frequently sought intervention by the rural health client, it would seem that registered nurses should be highly prepared and knowledgeable to meet these clients' needs.     

Nursing education in telehealth

Many nurses around the world provide expert nursing care through distance technologies but few undergraduate programmes expose nursing students to the full range of technologies available. Nursing education in telehealth needs to reflect the roles, responsibilities and capacity for knowledge building and innovation of the various constituencies within the profession. Registered nurses and advanced practice nurses will need complementary but different knowledge and skills than nurse administrators. The former will need technical proficiency in using common telehealth modalities and the ability to integrate telehealth in their practices.     

Cultural safety and the challenges of translating critically oriented knowledge in practice

Cultural safety is a relatively new concept that has emerged in the New Zealand nursing context and is being taken up in various ways in Canadian health care discourses. Our research team has been exploring the relevance of cultural safety in the Canadian context, most recently in relation to a knowledge‐translation study conducted with nurses practising in a large tertiary hospital. We were drawn to using cultural safety because we conceptualized it as being compatible with critical theoretical perspectives that foster a focus on power imbalances and inequitable social relationships in health care; the interrelated problems of culturalism and racialization; and a commitment to social justice as central to the social mandate of nursing. Engaging in this knowledge‐translation study has provided new perspectives on the complexities, ambiguities and tensions that need to be considered when using the concept of cultural safety to draw attention to racialization, culturalism, and health and health care inequities. The philosophic analysis discussed in this paper represents an epistemological grounding for the concept of cultural safety that links directly to particular moral ends with social justice implications. Although cultural safety is a concept that we have firmly positioned within the paradigm of critical inquiry, ambiguities associated with the notions of ‘culture’, ‘safety’, and ‘cultural safety’ need to be anticipated and addressed if they are to be effectively used to draw attention to critical social justice issues in practice settings. Using cultural safety in practice settings to draw attention to and prompt critical reflection on politicized knowledge, therefore, brings an added layer of complexity. To address these complexities, we propose that what may be required to effectively use cultural safety in the knowledge‐translation process is a ‘social justice curriculum for practice’ that would foster a philosophical stance of critical inquiry at both the individual and institutional levels.     

略谈骨科护理的发展现状及前景

随着医疗技术的不断进步以及骨科患者个性化需求的不断提升,骨科护理在整个医护过程中发挥着更加重要的作用,而护士的素质、水平直接影响着患者病情的康复效果。笔者对骨科护理的发展现状和前景进行了阐述和分析,并对护士的规范化护理提出了新的要求。     

Partnership working by default: district nurses and care home staff providing care for older people

Older people residents in care homes that only offer residential care rely on primary healthcare services for medical and nursing needs. Research has investigated the demands that care homes staff and residents make on general practice, but not the involvement of other members of the primary healthcare team. This paper describes two consecutive studies completed in 2001 and 2003 that involved focus groups and survey methods of enquiry conducted in two settings: an England shire and inner London. The research questions that both studies had in common were (1) What is the contribution of district nursing and other primary care services to care homes that do not have on‐site nursing provision? (2) What strategies promote participation and collaboration between residents, care home staff and NHS primary care nursing staff? and (3) What are the current obstacles and aids to effective partnership working and learning? A total of 74 community‐based nurses and care home managers and staff took part in 10 focus groups, while 124 care home managers (73% of the171 surveyed) and 113 district nurse team leaders (80% of the 142 surveyed) participated in the surveys. Findings from both studies demonstrated that nurses were the most frequent NHS professional visiting care homes. Although care home managers and district nurses believed that they had a good working relationship, they had differing expectations of what the nursing contribution should be and how personal and nursing care were defined. This influenced the range of services that older people had access to and the amount of training and support care home staff received from district nurses and the extent to which they were able to develop collaborative and reciprocal patterns of working. Findings indicate that there is a need for community‐based nursing services to adopt a more strategic approach that ensures older people in care homes can access the services they are entitled to and receive equivalent health care to older people who live in their own homes.