Understanding the Lived Experiences of Rural Nurses

Judith Paré, PhD, RN

ObjectivesUnderstand the differences between rural

and frontier health care settings.Define the philosophy and research

methodology of phenomenology.Describe Colaizzi’s seven-step method of

phenomenological analysis.Relate the impact of the identified themes to

nursing practice and future nursing research.

Words of Wisdom“We cannot protect nurses’ work unless we understand

it and act to preserve it when we are healthy.”Claire M. Fagin (Dean Emerita, University of Pennsylvania School of Nursing)

“The everyday management of a large ward, let alone of a hospital-the knowing what are the laws of life and death for men, and the laws of health for wards (and wards are healthy or unhealthy, mainly according to the knowledge or ignorance of the nurse)-are not these matters of sufficient importance and difficulty to require learning by experience and careful inquiry, just as much any other art?”Florence Nightingale

Rural SettingsThe U.S. Census does not actually define “rural.” “Rural”

encompasses all population, housing, and territory not included within an urban area.  Whatever is not urban is considered rural.

The Census recognizes that "densely settled communities outside the boundaries of large incorporated municipalities were just as ''urban'' as the densely settled population inside those boundaries." Their definition does not follow city or county boundaries and so it is difficult sometimes to determine whether a particular area is considered urban or rural.

In the 2010 Census 59.5 million people, 19.3% of the population, was rural while over 95% of the land area is still classified as rural.

Frontier SettingsFrontier areas are the most remote and geographically isolated

areas in the United States. These areas are usually sparsely populated and face extreme distances and travel time to services of any kind.

Although these general characteristics of Frontier are widely accepted, different organizations use different criteria to determine eligibility for their specific programmatic purposes.

NCFC uses low density and remoteness as the starting point and works with local agencies, such as the State Offices of Rural Health, to identify specific frontier areas in each state.  We believe that local agencies and communities best understand their unique, local conditions. Working with local agencies to identify frontier areas acknowledges the diversity among frontier communities.

Critical Access HospitalsWhat are critical access hospitals (CAH)?A Critical Access Hospital (CAH) is a hospital certified under a set of

Medicare Conditions of Participation (CoP), which are structured differently than the acute care hospital CoP. Some of the requirements for CAH certification include having no more than 25 inpatient beds; maintaining an annual average length of stay of no more than 96 hours for acute inpatient care; offering 24-hour, 7-day-a-week emergency care; and being located in a rural area, at least 35 miles drive away from any other hospital or CAH (fewer in some circumstances). The limited size and short stay length allowed to CAHs encourage a focus on providing care for common conditions and outpatient care, while referring other conditions to larger hospitals. Certification allows CAHs to receive cost-based reimbursement from Medicare, instead of standard fixed reimbursement rates.

Challenges & Opportunities in Rural Health Settingshttp://

www.ruralhealthweb.org/go/left/about-rural-health

The Story Begins: Chapter 1, Peterborough New Hampshire

Theoretical UnderpinningsColaizzi’s method of phenomenological psychology served as

the theoretical underpinnings for this research. Colaizzi was an existential phenomenologist who proposed that in order to best understand a human experience researchers must connect with that phenomenon as people experience it (Colaizzi, 1978).

Colaizzi believed that the phenomenologist must begin research by first examining his/her approach in order to uncover preconceived notions or biases about the research topic (Valle & King, 1978).

The questioning of these presuppositions about a phenomenon can lead the researcher to discover certain hypotheses, values, and attitudes that provide a foundation for the formulation of research questions.

Colaizzi’s Seven Procedural StepsStep #1: Read the subject’s transcriptsStep #2: Methodologically review each

protocol & extract statementsStep #3: Extract meaning for each significant

statementStep #4: Group meanings into categories that

reflect a cluster or themeStep #5: Define themesStep #6: Describe the phenomenonStep #7: Validate study findings

Data Collection The participants were each scheduled for a

20-30 minute initial interview. These interviews were held at the critical access hospital, in a private conference room. The participants self-selected the day and time of the interviews based upon lunch breaks, personal time, or after the end of a workday.

Study #1: Four participants (New Hampshire)Study #2: Nine participants (Montana)

Survey QuestionsHow many years of nursing experience do you have as a

registered nurse?What is your educational background? Are you currently

matriculating in a program to continue your nursing education?

Can you describe the various settings that you have worked in other than your current position?

What is your current position? How many hours per week do you work?

What is it like to work in a critical access hospital?Tell me about your nursing practice. Using Benner’s (1984)

model of novice to expert, how often do you feel good about your experiences at work? Please explain.

Demographic Data Study #1Characteristic n (%)Female 100%Employing Organization

Critical access facility (25 inpatient beds)Age

40-49 2 (50%)50-59 2 (50%)

Nursing Education Preparedness*RN DiplomaCurrently matriculating in a BSN program

1 (25%)

Associate’s Degree 2 (50%)Bachelor’s Degree 0Master’s Degree 1 (25%)

Years of Experience Working as a Registered Nurse1-5 1 (25%)6-10 1 (25%)11-20 1 (25%)20+ 1 (25%)

2014-International Rural Nursing Conference

Validating Survey FindingsStudy #1: The second interviews were scheduled

within 2-4 weeks of the initial interviews. During the second interviews the subjects were provided with written copies of transcripts from their initial interviews and asked to validate the text and meaning of their responses.

Study #2: All participants were offered the choice of Skype meetings, FaceTime, Telephone Conference Calls, U.S. Postal Mail, or Email to validate the text and meaning of their responses. All nine participants chose email communication.

Data Analysis & InterpretationThemes were identified using bracketing

analysis which involved listing patterns of experiences from the transcribed interviews on index cards, identifying data that related to the classified patterns & tagging these patterns into trends.

Coding & bracketing analysis revealed four essentials themes

Themes: Study #1ResponsibilityMentorshipIsolationSpirituality

Chapter 2: Miles City Montana

Demographic Data Study #2Characteristic n (%)Female 100%Employing Organization

Critical access facility (25 inpatient beds)Age

24-39 3 (33.3%)40-49 2 (22.2%)50-59 2 (22.2%)

Nursing Education Preparedness*RN DiplomaCurrently matriculating in a BSN program

0 (0%)

Associate’s Degree 6 (66.6%)Bachelor’s Degree 3 (33.3%)Master’s Degree 0 (0%)

Years of Experience Working as a Registered Nurse1-5 2 (22.2%)6-10 1 (25%)11-20 4 (44.4%)20+ 2 (22.2%)

Themes: Study #2Accountability

PersonalEducational Professional

EmpathyNurse-patientNurse-familyNurse-nurseNurse-organization

IsolationEmergent Leadership

AccountabilityPersonal: “I chose this job and it’s my job to

make sure that my skills stay sharp and a read up on any changes in practice.”

Educational: “I would love to get my BSN but I know that this will be my responsibility to pursue when I am ready.”

Professional: “I like going to conferences and being able to see my peers and hear about their experiences.” “There are limited options for professional growth when you are about 150 miles from any university setting.”

EmpathyNurse-patient: “Many of our patients are

older, fragile, and come with a lot of comorbidities.” “My heart goes out to them when we have to send them to Billings because their simply too sick for us to provide care.”

Nurse-family: “When we have to send patients to Billings for treatment, we are not only separating them from their medical staff and family members but we are also separating the family from their homes.:

Empathy (continued)Nurse-nurse: “The more experienced nurses

sometimes forget what it was like for them when they were new.” “There are times that I am uncomfortable asking questions.”

Nurse-organization: “We have gone through a lot of changes here and I am hoping that the recent change in leadership is as good as it seems to be so far”. “I wish that there was more recognition of the good things that we do; money is nice but a comment like “great job” sometimes is more valuable.”

Isolation“I really want to be certified in Emergency

Room Care but there weren’t any certification classes in the state this year. Last year I was scheduled to go and we were snowed in and the highways were closed so I couldn’t go.”

“The webinars are okay but it’s not the same as being their with the speaker and the audience; I need to touch and feel the topic in order to learn.”

Emergent Leadership“I feel like I am an old soul in a young person’s

body. I was meant to be a nurse and having the ability to be cross-trained allows me to be current and challenged every day.”

“Nursing isn’t about the technology it is about the person’s ability to deliver skilled compassionate care and that is what we do here.”

“We have a great team and we support each other because that is what our patients need and expect.”

“I always wanted to be a nurse in my home and Miles City is my home.”

LimitationsSample SizeGeographic LimitationsCultureBias

Future Areas for ResearchFurther research exploring the lived

experiences in urban, rural, frontier settings that provide care to a variety of consumer populations in a variety of geographic settings.

Case study research examining the lived experiences of nurses at various points of their careers in rural settings.

Experimental Design based research focusing on interventions to address the identified themes.

The Skill of Involvement“To be able to master what Patricia Benner has

called the skill of involvement nurses need to first know in order to then feel. Without their knowledge of cancer, diabetes, geriatrics, wound care, and so many other areas impossible to enumerate, nurses’ ignorance and anxiety would overwhelm their ability to be caring and compassionate. Perhaps they would be able to offer a kind word or gesture, but nurses’ healing work involves a great deal more than that.”Suzanne Gordon

References Benner P. (1984). From novice to expert: Excellence and power in clinical nursing practice. Reading, MA: Addison-Wesley.

Colaizzi, P. F. (1973). Reflection and research in psychology: A phenomenological study of learning. Dubuque, IA: Kendall/Hunt Publishing Company.

Colaizzi, P. F. (1978). Psychological research as the phenomenologist views it. In R. S. Valle & M. King (Eds.), Existential-phenomenological alternatives for psychology (pp. 48-59). New York, NY: Oxford University Press.

Conger, M. M., & Plager, K. A., (2008). Advanced nursing practice in rural areas: Connectedness versus disconnectedness. Online Journal of Rural Nursing and Health Care, 5(1), 24-38.

  Department of Health and Human Services Centers for Medicare & Medicaid Services. (2014). Critical access hospital: Rural health fact

sheet series. Retrieved from http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/CritAccessHospfctsht.pdf

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Australian Nursing Profession, 39(2), 163-71. Retrieved from http://ezproxy.snhu.edu/login?url=http://search.proquest.com/docview/1022985969?accountid=3783

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Louis, MO: Elsevier.  Hegney, D. (2002). Rural and remote area nursing: An Australian perspective. Online Journal of Rural Nursing & Health Care, 3(1), 24-38. 

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