Meet Pamela Stewart Fahs, holder of the Dr. G. Clifford and Florence B Decker Endowed Chair in Rural Nursing at Binghamton University, and Editor-in-Chief for the Online Journal of Rural Nursing and Health Care, and Audrey Snyder, an Assistant Professor of Nursing at the University of Virginia and nurse coordinator for Community Outreach at UVA Health System. Here’s what they have to say about the role of the rural nurse.
MP3 Audio Podcast
Jamie Davis: Hi and welcome both of you to Nursing Notes Live. One of the things I like to do at the beginning of each of these interviews is just ask you each to briefly share your background in nursing: why did you become a nurse and what led you through your career path to where you are today. Audrey, why don’t you go first?
Audrey: My experience with healthcare started with my grandmother being cared for in our home four about nine years. She was on a hospital bed and required nursing care that was provided by public health and home health nurses as well as the family. I learned a lot about nursing before I became a nurse. That really is what influenced me to take that career path. My background has been mostly in emergency critical care flight. Until about the last 10 years when I really began to identify a lot of the issues in the emergency department of reasons why patients were continuing to come back or why patients were coming in and being critically ill and having to be admitted to an ICU. A lot of them focused on patients just not getting access to healthcare. If a patient may have seen a physician yesterday or last month or three months ago or even last year, it may not be in the shape they’re in at this admission or at this time for us to actually have to admit them. So I have evolved in my work to focus more on access to care and how patients receive that care in trying to work with underserved areas. I’m currently teaching at the University of Virginia and I’m working with a nurse-managed clinic to actually improve access to care especially in regards to cardiovascular disease and pulmonary disease for patients. We’re also using that clinic as a site for our students who are going into predominantly family nurse practitioner as an educational degree. I also now work in a community hospital that’s in a rural area, part-time as a hospitalist as well.
Jamie: Fantastic. Pam, go ahead.
Pam: Well, I started in nursing about 30 years ago. I grew up in southeastern Kentucky, Harlan County, a small coal mining area. And I probably became interested in nursing because of the nurse that worked in our local clinic. She was an African-American woman who was very well-versed in nursing. I think the first thing that really attracted me to her role was how professional she looked when she went to work every day. Back in those days, there was the blue cape and the white uniform. I was very impressed with that. But then over the years, as I grew up in that community, I saw how she actually functioned in the clinic and she became a manager of the clinic. So she went from being a staff nurse to actually managing most of the patient care that occurred in that clinic. I had a very disconnected past into nursing. I was a high school dropout. I was in radio for a while. I did a lot of odd jobs. When I was 26, I decided I really needed to do something with my life and I kind of always thought about nursing and looked into getting into nursing and wound up going back and getting my associate degree and then my Bachelor’s and my Master’s and finally I finished my doctorate at the University of Alabama in Birmingham in 1991. During the time that I was beginning in nursing, one of my first jobs was in a small Appalachian regional hospital, one of the mining hospitals. One of the things that attracted me about rural health care and rural nursing was the generalist aspect of the nurse. That you have to be able to do a little bit of everything and do it well to be successful in rural nursing. I have continued to work with rural communities and rural nursing in many different ways. I primarily teach now but my research is focused on rural women in cardiovascular disease. I’ve worked with the University of Virginia. We finished the grant about two years ago on promoting heart health in rural women and I went down to Orange County, Virginia and Delaware County, New York. We looked at how to reduce women’s risk for cardiovascular disease. I currently work with a community group in Delaware County which is one of our most rural counties here in upstate New York. We’re working on looking at what are the priority health needs for people that lived in that rural county. As in many rural counties, health needs that come to the forefront often have to do with issues of access, chronic care, mental health promotion and substance abuse. Those are some of the areas that I’m working in currently. Then I teach in the only PhD in Rural Nursing program in the country here in Binghamton University.
Jamie: That’s exciting, Pam. And I think what I’ll do is lead in to you because you are teaching in that particular PhD program. Nurses have traditionally and historically been involved with care on the fringes of larger society and in the frontiers. And that tradition seems to be continuing with the focus of nurses being so actively involved in healthcare in the rural communities here in the United States and elsewhere around the world, do you see what you do as a continuation of the history of nursing?
Pam: I do. I think that one of our strong historical links is to Public Health Nursing and Community Nursing. I see that as very important in rural communities. I personally have also worked on more acute care type of settings and in dialysis and worked in critical care and cardiovascular and that type of setting. In rural communities, oftentimes, nurses wear many hats and one of the things that I see that occur, as Audrey was saying, is that you have a group of people who have less access to healthcare and once you get them into the system, getting the best care possible is critical. And I think that that’s one of the things as nurses were very good at, using scarce resources in a wise way. And I think that’s one reason rural nurses are so effective.
Jamie: Audrey, what are your thoughts? Certainly, you are actively involved in healthcare in rural setting and certainly there are opportunities for us to serve so many people in so many different ways, that multi-disciplinary approach that rural nurses are bringing.
Audrey: I think that’s very true. One area that I feel is kind of beginning to blossom and we need to ensure that rural nurses get training in this area is in the use of telemedicine. Because many areas lack specialty providers, there’s a lack of overall general primary care providers whether they’d be physicians or nurse practitioners. Many times, there’s also lack of specialty providers. And if we can have that initial specialty consultation or follow-up consultations done by telemedicine, then a nurse working in a rural area is very instrumental in having the technology training, being able to troubleshoot the equipment and to work with the patient to be the eyes and hands kind of with the patient with the specialist on the other end of the video and audio technology so that they can adjust cameras, provide vital signs or other information that the specialty consultant would need in working with that patient. And so that’s beginning to be seen as another way that we can increase access to specialty care for those people who are living in rural areas and saving them the time and distance have all this as well.
Pam: I think that’s a critical piece. Transportation is a huge issue in the rural community and if we can get telemedicine to work in an effective manner I think it could be an answer to a lot of our problems. There are issues out there with telemedicine that need to be followed in rural communities. There is varying amounts of access depending on the rural community that you’re in. Now healthcare settings and education sites have the best access in rural communities but it’s still a challenge in some areas. And the aging of technology and when you put a lot of money and time into equipment and then how well it’s utilized has been an issue over the years too. And then the final issue I think is, particularly, if you’re in rural areas that cross state lines, are the issues of state laws for practicing that we need to be aware of and need to address. But I do think that it’s an area where nursing can have a large impact and we really need to be leaders in advocating for telehealth in rural communities.
Audrey: One other factor related to that is reimbursement for this. So if we can continue to lobby for insurance reimbursements for the telehealth interaction, having them reimbursed at the same rate as a physician or a nurse practitioner were seeing the patient in their exam room because they are assessing, examining, treating those patients, it’s just it’s being done in a different mechanism. The technology is there for heart sounds to be listened to, for example, for Doppler’s to be used. So there’s good technology if the training is done and the local rural technology keeps up with the changes as there’s advances that are made.
Jamie: Audrey, what are some of the key challenges you see facing that educational curve? I know when I talk to a lot of nurses especially even about what I do recording this program, we are an aging profession and certainly there are some technophobia, if you will, associated with learning new technologies, does that extend into health technologies as well?
Audrey: I believe it does. I think that a key piece of it is (1) any time something’s new and there’s unfamiliarity, there’s a learning curve. So that means that education programs have to really focus on considering the learner. So our young nurses who are out of school in the most recent years, they’re the ones who adapt to that technology really rapidly. But for our nurses who may have done their first paper in school on a typewriter, they may have more difficulty although the concept of an electronic health record for all persons in the United States, means that almost all areas are now going to an electronic health record, so nurses have to have some familiarity with computers and computer systems and I think that it’s the key of education programs in having resources whether there’s been instructions that are with the technology and having someone maybe who’s on call at a distance who can help troubleshoot is really important. And so as those relationships are built with referral centers, having those relationships be where that there is someone that they can call and say, “I can’t make this work” or “The screen is blank, what else can I try?”, those sorts of things. And we all know that technology has the potential for failure. That’s inherent in the world that we live in today but more often than not, it does work and if we can just get people feeling comfortable, of course, the more encounters they have with doing that, it’s important. There’s a program that’s been developed at the University of Virginia Wise which is a small rural southwest Virginia community where that they were able to get grant funding to put telemedicine connections within their learning lab. And as the students are in school in our undergraduate nursing program, they’re being exposed to how the technology works and doing simulated patient scenarios so that they can get comfortable with the equipment that they will carry with them wherever they go to work. This exposure to actually using the technology and understanding the full concept as to how telehealth can work and be beneficial for the patient.
Pam: Understand the issues with technology, I think, Audrey, as you had mentioned, having technical support is critical to anyone but particularly if people have some discomfort with the level of technology. It can be a real buffer and make the telehealth more usable. Many nursing programs there though are using more and more electronic lab simulations. So I believe that our students continue through their educational process, they’re going to become more and more familiar with the electronic medical record and using technology. Nurses are very ethical. Many of us who have been around for a long period of time have learned new types of technology over a period of time and with support. It’s certainly doable. One of the things that I wanted to stress is that using the provider in the rural community, that nurse in that setting as a liaison with the telemedicine, is going to make the client or the patient more comfortable because that is one of the strengths of rural nursing is that you have that familiarity with your community and we have the familiarity with you. It can really be very helpful to the patient if they’re having to talk someone at a distance or a specialist, that nurse that’s there supporting that interaction through telehealth can also support the individual and their family through the normal nursing care that they would provide in that rural setting.
Jamie: What about the patient population in the rural setting? There’s a lot of research out there but primarily I think that research comes from urban centers and large metropolitan areas. Pam, is there a difference between the rural patient and patients in other parts of the system?
Pam: Well, I think, we all have cultural aspects to our lives and that morality can be part of the culture aspect. But if you look at somebody who’s in rural Alaska that’s very different than somebody who’s in rural Kentucky versus rural upstate New York. There’s some things that are the same across-the-board but there are differences also. So you really have to look at the individual, what their culture is, what they’re comfortable with. I think most of the research that has been done in rural health care shows that some of the strengths are the familiarity within communities; the community support that’s available; it’s a more personalized type of support. The fact that the rural nurse is a generalist has a broad view of nursing and healthcare and can intervene in different ways can be very helpful. There are some detractors from that too: the isolation, the transportation, the difficulty of giving the care. We know that rural clients who are under the age of 65 can have less access to healthcare for various reasons. There are different healthcare problems in rural and urban settings. But, overall, many of our healthcare issues, our chronic healthcare issues are really social, economic status issues. So lack of education, low socio-economic status, not enough employment in the area. All those actually play in to worsening health outcomes whether you’re in the rural are or you’re in the urban setting. If you have those kinds of factors going on, it’s a detractor to your health.
Jamie: Audrey, what are your thoughts?
Audrey: Well, I think at the same time there is the concept that everybody knows each other in a rural community. So a person, if they fear repercussions from whatever their symptoms, what the potential diagnosis might be, they may put off going in to get care. For example, if this was a patient who was afraid that they may have exposed to HIV virus and there’s a lot of stigma associated with that, they may delay getting care. There’s also lots of other reasons why people may delay getting care. Many times we’ve worked with women in particular and women in the rural environment especially in Appalachia will take care of their children, their husband, everyone else before they’ll take care of themselves. And so they put off self-care in order to care for others especially when there’s a cost factor associated with it. At the same time, what you find in rural areas is that people many times are very self-reliant. And they are less likely sometimes to go to the emergency department to get care for something that’s more minor. They’ll self-treat or they may use home remedies or they may use herbal therapies prior to actually going in, to actually talk with a physician and seek out other care. They’ll try other things first. They also are great, and this is not just our patients, but healthcare providers working in the rural areas, Pam mentioned earlier, are very creative. They are really good at being self-reliant, seeking out resources, working together to have better outcomes. Some of the concepts of public health is that you look to the community itself. So the work that I do with our research we always go to the community and what the healthcare providers in the community and the patients in the community talk about what their needs are and what they see as potential solutions to those needs. And that’s a key piece, kind of that participatory action and participatory research and that we try to do.
Pam: I would agree. That’s a key piece that I find in my practice in cardiovascular disease in the rural women is that two of those points you touched on, women taking care of other people first and then the piece about having community-based participatory research or action in healthcare is critical. The other thing I want to add is that one thing that technology need for nurses if there is a potential professional isolation in rural nursing. And technology can help in that area too because even if a system has money to send the rural nurse for further education or workshops or training, they may not have the coverage to allow them to go. There’s sometimes the risk if someone leaves the rural community to further their formal education, they won’t come back. And so using technology to advance professional education, I think is critical. I’m the editor of a journal, the Online Journal of Rural Nursing and Healthcare. There’s an article by Williams in the 2012 volume 12 that talks about professional isolation in rural nursing that I think rural nurses might be very interested in.
Jamie: How do we encourage more nurses to move into the rural setting? We talk all the time, I know in my programs and other places about the shortage of nurses, yet in some major metropolitan areas that’s absolutely not the case. There are plenty of nurses in some place but there is a shortage of nurses especially in the rural areas. How do we encourage our new nurses, our young nurses to want to move into that setting?
Pam: I think we have to let them know what rural nursing is. Provide preceptorships and learning experiences in rural communities. One of the real strengths of having a rural educational experience as a nurse is you get to see first-hand that collaborative process in rural healthcare. You get to appreciate that. And then putting programs into effect that will allow us to educate nurses in place and allow nurses to advance their education. Again, probably using technology is going to be our best bet for keeping nurses in rural settings. I do think there has to be some support that you can make a good living in a rural setting but that’s usually not the reason people leave. There are usually other reasons that people leave the rural setting. It’s usually not because of the money. And this oversupply, this temporary bubble that we have in urban settings, may be a good opportunity to bring nurses into rural settings. I’ve worked quite a bit with Idaho State University in their nurse residency programs that they’re using in rural settings. And that, of course, was highlighted by the Leadership in Nursing, Robert Wood Johnson, and IOM report as a key way to improve the nursing practice as nurses is to use residency programs. I think that’s a good way to get them into rural settings and support them as they begin their practice in rural settings.
Audrey: An additional thing I think that we can do while nurses are in training is to actually expose them to the rural area. So if there are opportunities with outreach clinics, with rural health clinics, to actually get them that exposure because we know that where a health professional grows up is where they usually will return to and most likely unless there’s something that intervenes there. If someone grows up in a rural area, they’re more likely to go back to a rural area. The challenge is that there is a lower population in the rural areas so there’s less number of people actually going into health professions. So we do need to supplement that by people who don’t grow up in a rural area. So if we can have this person who’s grown up in an urban environment for their lives and during their training to get this exposure to the rural environment and to see some of the benefits and understand the challenges and how nursing can make a difference with those challenges, I think sometimes we light that spark for students to be able to choose that as a location to practice.
Jamie: Audrey, any final thoughts as to a nurse or a student nurse out there thinking of looking at rural nursing as a career path?
Audrey: Well, I think that they need the exposure and one of the things that my students have reported back to us on is how much more time they get to spend with the patients when we’re doing clinics in a rural environment and the appreciation for how much a patient will reveal about themselves and about their challenges. At the same time, the gratification that the providers and the students will receive. Because many times these patients are just profusely thankful that you’ve been there to provide them with care and that exposure many times I think makes a difference for our students.
Pam: I would agree. Those are critical points. I do think that highlighting that the rural nurses are consummate generalists and is well-respected in the rural community and often is a leader in a rural community can help bring more people into rural nursing. By giving those clinical experiences in rural areas, getting residency program in rural areas where people actually get to have that experience is critical. And I would add that if nurses are interested in rural nursing, if they go to rno.org, it’s the Rural Nurse Organization. Our journal is open-source journal, so it’s free to everyone. We have a lot of manuscripts that address rural nursing from many different perspectives and I think it will be a good resource for rural nurses wherever they’re practicing.
Make sure you check out the entire June 2013 issue of Nursing Notes, looking at nursing in rural areas. You can read the entire issue online at www.discovernursing.com and don’t miss the other Nursing Notes Live episode this month where I interview our Get To Know Nurse Laurie Gross.You’ll find this and other podcast episodes at the Nursing Notes by Johnson & Johnson Facebook page, and in the podcast area in iTunes.