Orientation to Nursing in the Rural Community
Publication Year: 2000
Subject: Community / Public Health Nursing
This book examines the evolving health care delivery systems and the role of nursing within the rural context. Divided into three parts including perspectives from experts in Australia and Canada, the book covers the foundations of rural nursing, special populations, and future perspectives. Students of nursing will find special features in each chapter such as a list of objectives, key terms, points to remember, suggested research activities, and discussion questions.
- Front Matter
- Back Matter
- Subject Index
- Chapter 1: Nursing and Rural Health Care Delivery: Yesterday and Today
- Increased Awareness
- Historical Perspectives
- Cross-Cutting Issues
- Rural Nursing: The Big Picture
- Chapter 2: Definitions of Rural and Their Implications
- Federal Definitions
- Rural-Urban Continuum
- Chapter 3: Theoretical Foundations for Nursing in Rural Environments
- The Phenomenon of Ruralness
- A Theory for Nursing in Rural Environments
- Borrowed Theories Relevant to Rural Nursing
- Chapter 4: The Community Health Assessment (CHA) Process: Building Partnerships
- Background and Rationale
- Nurses as Partners
- Theoretical Perspectives
- The CHA Process
- Chapter 5: Exemplar: A Framework for Rural Nursing Interventions
- Structural Factors
- Sociocultural Factors
- Financial Factors
- Health-Seeking Behaviors
- Participation Mediators
- Service Utilization
- Outcome Mediators
- Chapter 6: Special and at-Risk Rural Populations
- Terms and Definitions
- Web of Causation, Risk, and Vulnerability
- Ethical and Legal Considerations
- Counterbalancing Forces
- Nursing Roles and Interventions
- Chapter 7: Cultural-Linguistic Competence: Rural Considerations
- Background and Rationale
- Minority Health Disparities
- Predominant Rural Minority Groups
- The Cultural-Linguistic Competence Continuum
- Dimensions of Culture: Rural Considerations
- Becoming Competent
- Chapter 8: Behavioral Health Care: Rural Issues and Strategies
- Availability of Providers and Services
- Linking Formal and Informal Resources
- Self-Reliance versus Dependency
- Advocating a Work Ethic
- Implementing and Evaluating Nursing Services
- Ensuring Anonymity and Confidentiality
- Client Satisfaction and Professional Burnout
- Chapter 9: Americaampnumx0027;s Lost Population: The Rural Homeless
- Background and Definitions
- Describing the Rural Homeless
- Contributing Factors
- Partnerships for Prevention
- Legal and Ethical Considerations
- Chapter 10: HIV/AIDS: The Silent Enemy within Rural Communities
- Epidemiologic Trends
- At-Risk Groups
- Social Isolation
- Access to Services and Providers
- Enhancing Resources for PLWAs
- Chapter 11: Rural Occupational Safety, Health, and Nursing
- Epidemiology of Rural Occupational Hazards and Injuries
- National Institute of Occupational Safety and Health (NIOSH) Rural Initiative
- Occupational Safety and Health Promotion Education
- Emergency Medical Services (EMS)
- Agriculture Health Nursing
- Nursing Research Needs
- Chapter 12: The Meaning of Managed Care for Rural America
- Evolution of the U.S. Health Care Delivery System
- Defining Managed Care
- MCOs and the Rural Market
- Chapter 13: Rural Nursing in the United States
- Nursing Workforce Trends
- Initiatives to Improve Access to Care
- Expanded Role Opportunities for Rural Nurses
- Rural Nursing: Rewards and Challenges
- Chapter 14: Rural Nursing in Australia
- The Australian Health Care System
- Health Status of Rural Australians
- Rural Health Services
- Initiatives to Restructure Services
- Defining Rural in the Australian Context
- Rural Nurses: Demographics
- The Scope of Nursing Practice
- Rural Practice Issues
- Chapter 15: Rural Nursing in Canada
- The Canadian Health Care System
- Health of Rural Dwellers in Canada
- Health Services in Rural Areas
- Defining Rural and Rural Nursing in the Canadian Context
- History of Rural Nursing in Canada
- Rural Nursing Demographics
- Scope of Nursing Practice
- Factors Affecting Rural Nursing Practice
- Chapter 16: Analysis of Rural Nursing: Australia, Canada, United States
- Reforming Health Care Delivery Systems
- How to Define Rural?
- Features of Rural Nursing Practice
- Visibility versus Anonymity
- Education, Recruitment, and Retention Issues
- Technology and the Global Village
- Rural Nursing as a Specialty Area of Practice
- Chapter 17: Ethical Situations: What Nurses in Rural Practice Should Know
- Background and Rationale
- Recognizing Ethical Situations
- Institutional Bioethics Committees
- Chapter 18: Research: The Link between Rural Theory and Evidence-Based Practice
- Why Rural Nursing Research?
- Rural Research Considerations
- Developing a Theory for Rural Nursing
[Page ii]This book is dedicated to Jack Andrea my parents my sisters and brothers and Q-tip, a little ghost-dog, who rarely left my side through the many months of writing
Copyright ampnumx00A9; 2000 by Sage Publications, Inc.
All rights reserved. No part of this book may be reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, or by any information storage and retrieval system, without permission in writing from the publisher.
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Printed in the United States of America
Library of Congress Cataloging-in-Publication Data
Orientation to nursing in the rural community / by Angeline Bushy.
Includes bibliographical references and index.
ISBN 0-7619-1156-1 (cloth: alk. paper)
ISBN 0-7619-1157-X (pbk.: alk paper)
1. Rural nursing. I. Title.
RT120.R87 B87 2000
This book is printed on acid-free paper.
05 06 7 6 5 4
Acquiring Editor: Rolf Janke
Editorial Assistant: Heidi Van Middlesworth
Production Editor: Sanford Robinson
Editorial Assistant: Nevair Kabakian
Designer/Typesetter: Marion Warren
Cover Designer: Michelle Lee
Since the publication of Rural Nursing, Volumes 1 and 2 (1991), the American health care system has changed dramatically. With the new paradigm, health care is less likely to be provided in acute care institutions and more likely to be delivered in a community-based facility. Health promotion and illness prevention are the buzzwords at the start of the new millennium. As the system evolves, outdated models are being redesigned, and new models of care delivery are emerging. Concomitantly, professional roles and responsibilities are being revisited. In turn, this affects the way nurses, physicians, and other health professionals practice in rural as well as urban settings. The purpose of this book is to examine the evolving health care delivery system and nursing role within the rural context.
Even though there have been significant changes in the health care system, in many cases the rural challenges remain the same as a decade ago. Rural nurses still must contend with factors that urban counterparts may not even be aware of. For instance, nurses and other kinds of caregivers in rural environments may need to provide cost-effective, quality services to a very sparse population living within a very large geographical area. Rural caregivers must be flexible and possess proficient generalist skills to creatively coordinate a continuum of care within the constraints of limited resources. Professionals in rural practice also must be able to establish, and sustain, peer support systems in regions that some would describe as geographically isolated. Those who live and work in rural communities often report that there is no clear separation between their professional roles and personal life. More often than not, urban-based health professionals are unaware of these and other practice-related issues. Nor are they knowledgeable about the rural lifestyle or the health care needs and preferences of residents in these communities. This book addresses that information deficitampnumx2014;not only for nurses in rural practice but for urban nurses who care for clients who live and work in rural catchment areas.
Citations on the topics of rural nursing and rural health care have increased phenomenally since the publication of Rural Nursing. Currently, most nursing journals include at least one article on some aspect of ruralness in each issue. Occasionally, some editors devote an entire issue to articles having a rural theme. The amount of research also has increased in the last decade as agendas of funding agencies have promoted the rural dimension. [Page xi]Likewise, nurses are being exposed to research-based presentations having a rural focus at regional, national, and international nursing conferences.
These combined efforts have produced greater awareness among educators of the need to expose students in the health professions to rural clients and rural environments. Many nursing educational programs are incorporating content on rural populations in their curricula. The need for information on the rural phenomenon will continue at both the undergraduate and graduate level, stemming from external political and professional mandates. This textbook is intended for individuals with little background on rural health care delivery systems. It can be used with various nursing audiences but is appropriate for other types of health professionals as well.
First and foremost, it is designed as the primary text for a graduate-level course. The content exposes students who are preparing for advanced roles (i.e., as nurse practitioners, nurse midwives, nurse administrators/managers, certified nurse anesthetists, and clinical specialists in acute and community practice settings) to the particulars of rural practice. Graduate students and faculty alike can use the book to examine current issues and future trends for professional nursing and health care delivery in rural environments from a global perspective. Second, the book can be used as a supplementary text for the traditional undergraduate community health nursing course with its in-depth perspectives on rural community-related issues. Third, it can be used for interdisciplinary (elective) courses that focus on rural health care delivery systems. Finally, it is my hope that practicing nurses who are working with rural clients, contemplating practice in a rural environment, or undertaking a research project having a rural focus will also use this book.
Orientation to Nursing in the Rural Community presents a wide range of rural topics. It is divided into three parts: ampnumx201C;Foundations of Rural Nursingampnumx201D; (five chapters), ampnumx201C;Special Populationsampnumx201D; (seven chapters), and ampnumx201C;National and Global Futuristic Perspectivesampnumx201D; (six chapters).
To assist the student in learning, each chapter includes objectives, key terms, essential points to remember, an overview, discussion questions, suggested research activities, and an extensive reference list. The appendices include a list of useful hypertext links (URLs) for accessing other resources and up-to-date information on rural health care delivery, rural nursing, rural communities, and specific rural populations (Appendix A); maps of nonmetropolitan and frontier counties (Appendices B and C); a list of significant pieces of legislation that have affected rural health care delivery (Appendix D); and maps of health professional shortage areas and persistent poverty counties (Appendices E and F).
This edition celebrates what nurses in rural areas have accomplished over the centuries. Hopefully, it will also stimulate a vision of what can be accomplished by nurses within our global village as we continue to meet the health care needs of rural residents in new and creative ways.
When preparing Rural Nursing (Vols. 1 and 2), I never imagined that one day I would be writing another book on the topic. Many things in rural practice seem to stay the same. Yet the need for an updated version of these edited texts became evident to me several years ago on the basis of feedback from practitioners, educators, students, and researchers across the nation. Their encouragement motivated me to write Orientation to Nursing in the Rural Community, which provides information on the changing health care delivery system and nursing practice within the rural context. However, many others also need to be recognized and thanked as this book is being published.
I gratefully acknowledge all of the rural nurses from across the nation with whom I have worked and spoken over the decades. Your ideas are integrated throughout this book. I appreciate, too, the authors who contributed the three chapters to this book. They willingly shared their expertise to provide an international perspective and develop an exemplar that can be used to develop interventions for rural populations.
My appreciation must extend to the Bert Fish Foundation. They established the Endowed Chair that I am honored to hold at the University of Central Florida School of Nursing. Their interest in the health care needs of the underserved encouraged me to learn and write about rural groups that I was not aware of when preparing the first editions of this text.
Thanks to my friends and colleagues, especially Dr. Elizabeth Stullenbarger, director of the University of Central Florida School of Nursing. Without their understanding and support, this book would never have reached completion.
I want to acknowledge Sage Publications, particularly Dan Ruth and Heidi Van Middlesworth, for their assistance and encouragement.
My family again deserves much credit for my accomplishments over the years. They have been very understanding and extremely tolerant when I leave family gatherings to work on book revisions and finish some writing that always should have been done ampnumx201C;yesterday.ampnumx201D; I sincerely appreciate what you have all done, with and for me, during this entire process.
Appendix A: Hypertext Links to Access Internet Sites Related to Rural Nursing[Page 265]
Hypertext links can provide additional information related to at-risk and vulnerable populations. Because URL addresses change frequently, the reader may need to access these sites through other addresses. These are starting points to additional information for designing and providing health services for special populations.
Site Name and URL Type of Information Agency for Health Care Policy and Research http://www.ahcpr.gov Research, clinical, and preventive guidelines Alternative medicine http://www.altmedicine.com Complementary and holistic health care American Public Health Association http://www.apha.org Public health, vulnerable populations Association of Community Health Nursing Educators http://www.health.uncc.edu/achne Links to other sites and information on community health nursing issues, practice, and education Association of Telemedicine Service Providers http://www.atsp.org Telemedicine-related news and resources; online journal Bureau of Primary Health Care http://www.bphc.hrsa.dhhs.gov Health promotion and disease prevention Bureau of the Census http://www.census.gov Census data, maps, research links Center for Patient Advocacy http://www.patientadvocacy.org Managed care information Centers for Disease Control and Prevention http://www.cdc.gov Data, prevention and control of disease; links to federal and state resources Childrenampnumx0027;s Health Insurance Program (CHIP) http://www.hcfa.gov/init/children.htm State activities for childrenampnumx0027;s financial access to health services [Page 266] Community Campus Partnerships for Health http://futurehealth.ucsf.edu/ccph.html Academic-community models for special populations Consumer Information Center http://www.pueblo.gsa.gov Consumer information Council of Ethical Organizations http://www.ethicsandcompliance.com Ethics resources Environmental Protection Agency http://www.epa.gov Information on environmental issues Families USA http://www.familiesusa.org Managed care information Food and Drug Administration (FDA) http://www.fda/gov/fadhomepage.htm Food, nutrition, and drug information Health Care Financing Administration (HCFA) http://www.hcfa.gov Health care delivery system issues and resources Health Care for the Homeless Information Resource Center http://www.prainc.com/hch Clinical information and resources, recommendations for policy and practice, Web-based study modules on special issues in health care of homeless Health Resources Services Administration http://www.hrsa.dhhs.gov Links to managed care information related to special populations Health United States http://www.cdc.gov/nchswww Data on income, education, and health status of U.S. communities Healthy People: 2010 http://web.health.gov/healthypeoplehttp://www.cdc.gov/nchs National goals and strategies for promoting health and reducing illness; emphasis on highrisk populations Indian Health Service http://www.ihs.gov American Indians and Alaskan Natives International Healthy Cities Foundation http://www.healthycities.org Objectives, strategies for healthy communities movement Medicaid http://www.hcfa.gov/medicaid/medicaid.htm Data, program, and policy information Medicare http://www.hcfa.gov/medicare/medicare.htm Data, program, and policy information National Cancer Institute http://www.nci.nih.gov Cancer information National Clearinghouse for Alcohol and Drugs http://www.health.org Information on alcohol, drugs, substance abuse National Clearinghouse on Child Abuse http://www.calib.com/nccanch Domestic violence and neglect [Page 267] National Coalition for the Homeless http://nch.ari.net On-line library, links to organizations National Committee for Quality Assurance http://www.ncqa.org Agency accreditation; consumer issues National Health Information Center http://nhic-nt.health.org Health-related information National Health Service Corps http://www.bphc.hrsa.dhhs.gov/nhsc Preparation, recruitment, and retention of community-responsive primary care clinicians National Institute for Nursing Research http://www.nih.gov/ninr News, Priority Expert Panel reports on health care issues, diversity programs, and resources National Institute of Mental Health (NIMH) http://www.nimh.nih.gov News on mental health issues, research fact sheets, statistics, and reports, patient education materials National Institute of Occupational Safety and Health http://www.cdc.gov/niosh Workplace safety issues, programs National Institute on Aging Information Center http://www.nih.gov.nia Aging and gerontology National League for Nursing (NLN) http://www.nln.org Nursing education research priorities and disseminating strategies, identified by the NLNampnumx0027;s panel National Library for the Blind and Handicapped http://www.lcweb.local.gov/nls Resources for the blind and physically handicapped National Maternal Child Health Clearinghouse http://www.cirrcsol.com/mch Maternal child health National Rural Health Association http://www.nrharural.org Rural health issues and minority health disparities National Rural Nurses Organization http://www.nro.org Information and links for rural nursing Newsletters on Line http://www.newslettersonline.com Links to health-related publications Nursing Center http://www.nursingcenter.com Links to numerous nursing journalsampnumx0027; articles; forum discussions; means to earn CE credits on line Office of Disease Prevention and Health Promotion http://odphp.osophs.dhhs.gov Information on income, education, and health status Office of Minority Health Resources Center http://www.omhrc.gov Minority health issues/cites Office of Rural Health Policy (USDA) http://www.nal.usda.gov/orhp Programs, research, publications, links, and an information service on rural health care [Page 268] Parish Nursing http://lewis.up.edu/nrs/parishnurse Resources to work with a faith community Policy Research Associates, Inc. http://www.prainc.com Has information resource center on health care for homeless Presidentampnumx0027;s Initiative on Race http://aspe.os.dhhs.gov/race Health disparities among racial and ethnic groups; DHHS goals and plans Primary Care Clinical Practice Guidelines http://medicine.uscf.edu/resources/guidelines Resources for primary care providers, including evidence-based guidelines PubMed and Grateful Med http://www.ncbi.nlm.nih.gov/PubMed/news.htmlhttp://www.ncbi.nlm.nih.gov/PubMed/news.html MEDLINE, the National Library of Medicineampnumx0027;s database, search and link capabilities Rural Information Center (USDA) http://www.nal.usda.gov/ric A service offering information and referrals for rural communities, officials, organizations, and citizens Sheps Center for Health Services Research http://www.shepscenter.unc.edu Oldest and largest health services research center. Has numerous links to other rural sites Substance Abuse and Mental Health Services http://www.samhsa.gov Preventing and treating substance abuse and mental health problems U.S. Department of Agriculture http://www.usda.gov Agroeconomic and related health issues U.S. Department of Health and Human Services http://www.os.dhhs.gov Programs for special populations
Appendix B: Nonmetropolitan Counties, 1997[Page 269]
Appendix C: Frontier Counties, 1994[Page 270]
Appendix D: Legislation Affecting Rural Health Care[Page 271]
Year Legislation Intent and Provisions 1948 Hill-Burton Act Provided for construction of health care facilities where these were lacking. Many rural communities built hospitals with these funds. A number of these hospitals currently are experiencing economic problems and are on the verge of closing. 1954 Transfer Act Provided that all functions, responsibilities, authorities, and duties related to the maintenance and operation of hospitals and health facilities and the conservation of Indian health be administered by the Surgeon General of the U.S. Public Health Service. 1957 Indian Health Assistance Act Provided for construction of health facilities for Native Americans. 1962 Migrant Health Act Authorized federal aid for clinics serving migratory agricultural workers and their families. 1964 Economic Opportunity Act Provided a legal framework for the antipoverty program. 1968 Neighborhood Health Centers Extended grant to migrant health services. 1970 Health Training Improvement Act Provided expanded aid to allied health professionals. 1971 Comprehensive Health Manpower Training Act Increased federal programs for development of health care workers. 1972 Health Service Corps Act Encouraged health professionals to practice in areas designated as HPSAs. 1973 Health Maintenance Organization and National Health Planning and Resource Development Act Increased health insurance coverage for the rural population. 1975 Indian Self-Determination Act Gave tribes the option of staffing and managing Indian Health Service programs in their communities and provided for funding for improvement for tribal capability to contract for health care services. [Page 272] 1976 National Consumer Health Information Act Provided medical services in areas with an insufficient number of physicians. 1976 Indian Health Care Improvement Act Intended to elevate the health status of Native Americans and Alaska Natives to a level equal to that of the general population by authorizing a higher budget for the Indian Health Service. 1977 Rural Health Clinics Service Act Provided medical services in areas with an insufficient number of physicians. 1981 Planned Approach to Community Health (PATCH) Provided funding to states for delivery of preventive care and health promotion to rural communities. 1981 Omnibus Budget Reconciliation Act (OBRA) Consolidated categorical grant programs into block grants that served to increase state discretionary use of federal monies (block grants for maternal and child health, services for disabled and other children with special health care needs, Supplemental Security Income services for disabled children, hemophilia treatment centers, and other programs aimed at specific groups or health problems). 1991 NIOSH Agricultural Health Initiative In recognition of the high morbidity and mortality rates in this industry, focused efforts to address the problems of health and safety in the industry. 1996 Welfare to Work Act Intended to reduce number of welfare recipients, increase productivity of dependent members of society, and reduce intergenerational dependency. 1997 Rural Hospital Flexibility Program (Sec. 4201 of the Balanced Budget Act) Created options for struggling small rural hospitals with designation of ampnumx201C;critical access hospitalampnumx201D; 1986ampnumx2013;2000 Decentralized (state) control over health care programs Added amendments to existing federal health care legislation to revise policies.
Appendix E: Health Professional Shortage Areas (HPSAs), 1997[Page 273]
Appendix F: USDA County Type: Persistent Poverty, 1989[Page 274]
About the Author[Page 281]
Angeline Bushy, PhD, RN, CS, holds the Bert Fish Endowed Chair at the University of Central Florida, School of Nursing, where she is a professor. She holds a BSN. from the University of Mary at Bismarck, North Dakota; an MN in Rural Community Health Nursing from Montana State University; an MEd in Adult Education from Northern Montana College; and a PhD in Nursing from the University of Texas at Austin. A clinical specialist in community health nursing, she has lived and worked in rural facilities located in the north central and intermountain states. She has published and presented internationally and nationally an various rural nursing and rural health issues. She has edited the textbooks Rural Nursing: Volume I ampnumx0026; Volume II and coauthored Exploring Rural Medicine: Current Issues and Concepts and Special Populations in the Community: Advances in Reducing Health Disparities. Her research focus is on the health care needs of rural populations and the education, role, and scope of rural nursing practice. She is actively involved with Web-based distance education and is a lieutenant colonel in the U.S. Army Reserve. Angie and her husband Jack, a social worker have one daughter, Andrea Dacyl, who is also a social worker.[Page 282]
About the Contributing Authors[Page 283]
Kathryn Baird-Crooks, MEd, RN, has been an instructor in the Division of Health Studies at Medicine Hat College for the past ten years. She has had a varied career in nursing, primarily in rural acute care. She developed one of the first rural nursing courses in Canada. She has published and presented papers in the area of rural nursing nationally as well as internationally.
Jeri Dunkin, PhD, RN, is Associate Professor and holds the Saxon Endowed Chair in Rural Nursing at Capstone College of Nursing, The University of Alabama, Tuscaloosa. She has been involved with rural health care for many years and is editor of the Online Journal of Rural Nursing and Health Care. Her research focus is in the area of health promotion of rural populations, particularly with respect to environmental factors and asthma. She is actively involved in distance learning using technology and the Internet. Jeri and her husband are very proud of their seven grandchildren and enjoy touring on their Goldwing motorcycle.
Joyce Engel, PhD, RN, is Dean in the Division of Health Studies at Medicine Hat College. She has been proactive for rural nursing education and was instrumental in offering one of the first such courses in Canada. She has published and presented papers nationally and internationally in the area of rural nursing.
Desley Hegney, PhD, is Professor of Rural Nursing at the University of Southern Queensland and the Cunningham Center, Toowoomba Health Services, Toowoomba, Queensland, Australia. She is the editor of the Australian Journal of Rural Health and currently is president of the Queensland Branch of the Association for Australian Rural Nurses Inc. She has had many years of experience in rural nursing and is recognized internationally as an expert on rural practice issues.
Gail Remus, RN, MN, is Associate Professor and Co-ordinator of the Post Registration Nursing program at the College of Nursing, University of Saskatchewan. Prior to coming to the University of Saskatchewan in the mid-1980s she worked as a community health nurse and a home care co-ordinator in a rural community within that province. She and her husband continue to be actively involved in farming; they have two children and four grandchildren.
[Page 284]Donna C. Rennie, PhD, RN, is Associate Professor in the College of Nursing and in the Centre for Agricultural Medicine, College of Medicine, University of Saskatchewan. The focus of her research is respiratory epidemiology, in which she holds a doctorate. She teaches a rural nursing course offered by distance to registered nurses enrolled in a post-diploma nursing program at the University of Saskatchewan. She grew up in rural Manitoba and spent many years as a nurse in northern Manitoba.