37 WHAT RURAL NURSING STORIES ARE YOU LIVING? Kay Rosenthal, PhD, RN1 1 Executive Director, Estes Park Medical Center, CO, EPLTR@aol.com Keywords: Rural, Generalist, Nurse, Stories, Narrative, River, Theme, Metatheme ABSTRACT This article illuminates the lived experience of rural generalist nurses who work in an acute care hospital with less than twenty-five beds located in a mountain setting. Interviews of eight nurses were analyzed to develop a metatheme "Rural Nursing: Flowing Like A River" and four themes, which emerged from the data. The themes included: Going With the Flow: Fluid Role; Fish Out of Water: Expert to Novice; Still Waters Run Deep: Self Reliance; and Life in a Fish Bowl: Contextual Knowledge of Patients. Stories were co-created by the researcher; one, "Code Blue Boots," is included. CODE BLUE BOOTS "Code Blue" I stand to help. "I'll go to ED to help. I'll be back later. I'm just going to leave all my stuff here." "OK. We'll move 'em if they get in the way, but we won't toss 'em." They love to tease me, always joking that they're going to throw my statistics away! I hear my boots clomp, clomp, down the hallway all the way to the ED. As I enter the room everyone stops momentarily, turns and looks at me! "I can't believe it! You've got those ----boots on!" Paula says and glares at me. Paula gives me a sketchy report and it hits me! Not only do I have on my Code Blue boots but also we are doing one of the MOCK COR scenarios I wrote last night, except this is the real thing. My mind drifts to think of the scenarios I've recently written: SIDS (sudden infant death syndrome), yes, we've just done one. Hypothermia, yes, that car accident where the kids walked in to tell us there had been an accident; they were really hypothermic when the ambulance got to the scene. Motor vehicle accident (MVA), yes we had done the MVA scenario, the car had even been kept from falling off the highway by a tree as I had imagined. You know, I think I've written eight scenarios, and we've done them all! I'm not writing any more. The Code has ended, it has not been successful. Alice asks if she should give the last of the epinephrine (epi). "There's a little left in the ampule. Should I give it?" "I don't care." the doctor replies. Alice says, "Well, I hate to throw it away, I'll just give it." She pushes the rest of the epi. A minute later she says, "Doctor, there's a heart beat! Oh my God! There's a heart beat!" Online Journal of Rural Nursing and Health Care, vol. 5, no. 1, Spring 2005 mailto:EPLTR@aol.com 38 He runs back over. Steve, the paramedic, starts bagging again and we call for the helicopter. Alice can't believe it. "I'm just so frugal! I just couldn't stand to throw it away!" Inside she is terrified, will there be brain damage? Has she done something really, really good or really, really bad? Was this a miracle? She wonders. The Code continues, the patient is stabilized. The Code Blue is finished, we've succeeded again. We have a Computed tomography (CT) scan but this guy, now that the Code Blue is over and we have stabilized him, really needs a magnetic resonance image (MRI); we have a surgeon but this guy needs a neurosurgeon so it's off to Metro for him. Helicopter is here so I head back to the floor. I hear the familiar clomp, clomp, clomp of my boots and think to myself, I'm not wearing these boots again either! (Rosenthal, 1996, p. 92-94). INTRODUCTION In the modern world of specialty nursing, rural nursing offers many unique challenges to the nurse who functions as a generalist. Nurses share stories of shifts where they were acting in the role of physician until he/she arrived in the Emergency Department, then changed to hospice nurse at the bedside of a dying patient, and ended their day in the role of neonatal nurse during the delivery of a baby. These typical rural nursing shifts create struggles, opportunities, and threats to generalist nurses that are specific to the practice of rural nursing. This article will review research available in the literature and report supporting and unique findings of the author's study (Rosenthal, 1996). REVIEW OF THE LITERATURE Long & Weinert (1992) define rural nursing as “the provision of health care by professional nurses to persons living in sparsely populated areas” (p.390). Characteristics of rural nursing described in the literature include: the need for the rural nurses to assume the role of generalist and function as jack-of-all-trades; lack of anonymity; flexibility; versatility; adaptability; working in a broad spectrum of clinical settings; performing many unrelated and diverse tasks; resourcefulness; culture consciousness; self-reliance; and skills in obstetrics, maternity, intensive care, and emergency room nursing; filling professional as well as nonprofessional roles; professional isolation; insider-outsider status based on the length of time in the community; all of the above descriptions (Cozzi- Burr, 1992; Biegel, 1983; Bond et al. 1984; Thobaden & Weingard, 1983, Ross 1979; Long & Weinert, 1992; Scharff, 1987; Hamel-Bissell, 1992). There is limited literature (Rosenthal, 1996, 2000) from the rural nurses’ perspective regarding the rewards, threats, and/or challenges of rural nursing. This perspective is important in order to recruit students and experienced nurses in the rural setting, enhance the esteem of rural nurses, and elevate rural nursing to a specialty within the practice of professional nursing. Through the use of narrative (stories) these issues are explicated. Online Journal of Rural Nursing and Health Care, vol. 5, no. 1, Spring 2005 39 METHOD There is much discussion in the nursing and education literature regarding the use of stories (Heinrich, 1992; Boykin & Schoenhofer, 1991; Van Manen, 1990; Benner, 1991; Connelly and Clandinin, 1990; Vezeau, 1992; and Witherell & Noddings, 1991). Storytelling is everywhere. People are keeping journals, writing family histories and their own biographies (Witherell & Noddings, 1991). Stories are being used to help people make sense of their lives (Greene-Hernandez, 1992). People are finding their voice through narrative (Belenky, Clinchy, Goldberger, & Tarule, 1986). Narrative provides a form through which matters that would remain untold about our daily lives are shared. Stories engage readers and prod us to think in new ways. The use of narrative in research is demonstrating the usefulness of findings within a context instead of as sterile, detached findings. Subject-object separation is no longer the only method valued. Because people use narrative to organize their lives into meaningful units, researchers are able to identify the patterns embedded in the narrative (Polkinghorne, 1988). Qualitative researchers who are interested in "lived experiences" elicit nurses' stories and have explicated the complexity of nursing by recording nurses' stories of their professional experiences (Boykin & Schoenhofer, 1991). Stories are powerful tools that may be used to convey deep feelings and meanings (Heinrich, 1992). Stories provide rich texts for interpretive phenomenological research studies (Benner 1984, 1991). Stories are being used in the classroom to link theoretical and clinical practice by reconnecting with our subjective feelings. Counselors and educators are using story and narrative as professional tools; educators are recognizing that the quest for meaning is an important aspect of education; and narrative is being used as a multidisciplinary and multicultural model for teaching (Connolley & Clandinin, 1990; Witherell & Noddings, 1991). Nursing's ways of being (ontology) are gleaned from studying nursing situations. Story grounds nursing's ways of knowing (epistemology) within the ontology of relationship, meanings and context. Thus story's major contribution to the profession of nursing is the meaning of our own practice gained from the insight and deepened understanding of practicing nurses (Boykin & Schoenhofer, 1991). AIM The aim of this study was to describe the lived experience of rural nurses through their stories. The design, exploratory descriptive, encouraged nurses to tell stories of their experiences working in a rural acute care hospital. An exploratory descriptive design was chosen to explore the little-studied situation of the rural nurse generalist. This design is appropriate to study topics about which little is known (Brink & Wood, 1989). The use of narrative, with its emphasis on life-like, understandable, plausible stories, offers the best method to discover and describe the lived experiences of rural nurses. RESEARCH QUESTION What are the stories told of the lived experience of rural generalist nurses who work in an acute care hospital, with less than twenty-five beds, located in a mountain setting? (Rosenthal, 1996). Online Journal of Rural Nursing and Health Care, vol. 5, no. 1, Spring 2005 40 SETTING/SAMPLE After obtaining permission from the University Review Board two rural hospitals with less than twenty-five beds were selected. These hospitals are located in western mountain communities, in the United States. The study sample was composed of eight nurses (seven registered nurses and one licensed practical nurse), recruited by the director of nurses of the hospital, who agreed to participate in the study. See table 1. Table 1 Demographics Hospital Nurse Age Sex Ethnic Education Rural/ Clinical A 1 44 F C DIPL N/N A 2 66 F C DIPL N/N A 3 52 F C ASSOC N/N A 4 39 F C LPN Y/Y B 5 44 F C BSN N/N B 6 51 F C DIPL N/N B 7 36 M C ASSOC N/N B 8 56 F C DIPL N/N Work Status Total Years Rural Nursing % Career in Rural Nursing FT 23 20 86 FT 40 28 70 FT 4.5 4.5 100 FT 19 19 100 PT 22 18 81 FT 20 26 86 FT 3 2 66 FT 34 34 100 Key: Female (F) Male (M); Caucasian (C); No (N) Yes (Y) Full Time (FT) Part Time (PT) Rural Nursing Clinical offered in Nursing Program /Participated in Rural Clinical The nurses were assured confidentiality of the research findings. Signed consents were obtained from all participants and verbal consents were obtained prior to tape recording all interviews. Staff nurse names and specifics of situations were changed to assure confidentiality. Interviews were tape recorded and transcribed by the researcher. Online Journal of Rural Nursing and Health Care, vol. 5, no. 1, Spring 2005 41 DATA ANALYSIS Data analysis for this study had two distinct aspects that were based on tape- recorded and transcribed interviews with rural generalist nurses. One was the identification of themes with supporting subthemes and exemplar transcripts (Rosenthal, 1996, 2005). Four themes emerged from the data based on the transcripts from the nurses’ interviews. These themes were: Going With the Flow: Fluid Role; Fish Out of Water: Expert to Novice; Still Waters Run Deep: Self Reliance; and Life in a Fish Bowl: Contextual Knowledge of Patients. The second aspect of data analysis was the creation of a poem which illuminates the metatheme that emerged from the study findings, titled “Rural Nursing: Flowing Like A River,” as well as narratives that are stories rewritten by the researcher (Rosenthal, 1996, 2005). See Rosenthal (1996) for a full description of the metatheme, themes and subthemes with supporting transcript excerpts. STORIES The stories were written after reflection on the transcripts and the creative process of writing by the researcher. These stories are original creative outcomes written by the researcher, which came out of material from the transcripts. The unique rendering of the stories came from the data. This process used the researcher-as-instrument and refers not only to the researcher’s own influence on what was studied, but also refers to the limitations and creative possibilities of how the researcher decided to study the phenomenon and her/his ability to make sense of the data during analysis (Oiler Boyd & Munhall, 1993). RIGOR Rigor was established through the use of Sandelowski’s (1986) four criteria for rigor in qualitative research studies. Truth value was established through credibility defined as a faithful description or interpretation of the data, which was confirmed by the nurses involved in the study and two nurses from a third rural hospital. Sandelowski's second criterion, applicability, was demonstrated by a review of the literature, which confirmed "fittingness." The third criterion, consistency, defines the auditability of the findings. The study should have consistent findings, in terms of themes. Noting that the details interwoven from the interviews in the form of stories would vary even if the same data were used by a different researcher following the decision trail of the initial researcher. The fourth criterion, neutrality, addressed confirmability of the study’s findings. This final criterion pulled together the initial three: auditability, truth value and applicability and acknowledges the bias built into the study. Sandelowski notes that in qualitative studies bias, acknowledged and accounted for, it is not controlled for or eliminated. Online Journal of Rural Nursing and Health Care, vol. 5, no. 1, Spring 2005 42 ETHICAL CONSIDERATIONS Ethical considerations center around beneficence and fidelity. Beneficence, or the obligation to do no harm, was of importance in the protection of the participant. Fidelity regarding the promise of confidentiality is paramount. STUDY LIMITATIONS One limitation of this study may be the issue of face-to-face interviewing. Informing the nurses that the researcher worked in a rural setting could be a limitation. A third limitation of this study was that the researcher and the storyteller are the same person, therefore only the researcher’s perception of the nurses' stories was represented. Another limitation of this study may be that the researcher's showing of empathy may have broadened the story as the nurse felt encouraged to proceed by my obvious interest and encouragement. Perhaps the active sharing of stories between researcher and participant would have triggered other stories in the mind of the participant. However, there is a danger of leading or manipulating the participant if the researcher is too involved in the conversation (Tochon, 1992). Finally, some of the nurses were on duty and may have felt rushed during the interview process or may have felt time pressures from tasks left undone that they sensed a need to complete. This may have limited the length of participation. STORIES OF RURAL NURSING The creative outcomes of the interviews of rural nurses are a compilation of stories explicating the lived experience of rural nurses written by the researcher (Rosenthal, 1996, 2005). The stories are written in the first person so that emotions can be expressed; however the stories are not the researcher's personal stories. The stories were based on the data but were adapted. Therefore, certain aspects of the stories are fictionalized, i.e., names of participants, date, time, place, quoted dialogue. However, the gist of the stories' situations and events are true to the transcripted interviews of the participating nurses. The stories were created as a literary device. Six stories (Rosenthal, 1996) were written, titled: "Injured? Dying? This Can't be Happening!"; "Man, am I a Good Metro Nurse! I'll Show Those Rural Nurses a Thing or Two"; "Code Blue Boots"; "We're All in This Together"; "Western Slant"; and "Orientation, You Call This Orientation?" One of the co-created stories from the perspective of rural nurses as rewritten by the researcher, “Code Blue Boots,” was presented at the opening of this article. FINDINGS From the interviews with rural nurses several themes recurred in the review of the rural nursing literature, such as the need for rural nurses to assume the role of generalist and function as "jack-of-all-trades" (Long & Weinert, 1992; Cozzi-Burr, 1992; Ross, 1979). The generalist nurses must be prepared with a broad scope of nursing skills in order to function independently and to respond appropriately to the unique challenges Online Journal of Rural Nursing and Health Care, vol. 5, no. 1, Spring 2005 43 presented in the clinical arena (Ginsberg, 1982). The need for the rural nurse to have a broad experiential background as well as a broad spectrum of clinical settings (Ross, 1979; Long & Weinert, 1992) was consistent with the theme Fluid Role (Rosenthal, 1996, 2005). A third theme appearing in the literature indicates that rural nurses are expected to fill non-professional roles as well as roles of other professionals. The nurse may be required to draw blood, and spin the hematocrit, until the lab technologist arrives to further process the sample. The nurse frequently performs twelve-lead electrocardiograms (EKG) and assists patients with pulmonary function tests, incentive spirometry, percussion and postural drainage, since rural hospitals typically do not have EKG technicians and/or respiratory therapists on staff. The nurse may also function as dietician, pharmacist and even "runner" (Long & Weinert, 1992; Ross, 1979; Scharff, 1987). Fluid Role (Rosenthal, 1996, 2005) in this study described these same issues. The fourth theme, lack of anonymity and what sociologists call "role conflict," is described in the rural nursing literature because in small towns everyone knows everyone's name. In the small rural hospital this means that you recognize the address of the patient being brought into the emergency department when you get the call from the dispatcher. The rural nurse also sees the look of relief when the patient recognizes her. Lack of anonymity speaks to the difficulty of maintaining private areas of nurse’s lives. Rural nurses occupy multiple identifiable role positions in small towns and are well known as neighbors, church members and family members. Rural patients are also known by the rural nurses in several personal as well as social role relationships. In a small town the nurses’ roles as parent, spouse, and church member are all related to their effectiveness as nurses (Long & Weinert, 1992). These issues are described in the theme Contextual Knowledge of Patients in this study (Rosenthal, 1996, 2005) The fifth theme, the concept of "insider/outsider," is identified in the rural nursing literature. Rural nurses are aware of the long period of residency in the community before the community members will consider the nurse an "insider." Nurses recognize the importance of belonging and of participating in community events, being members of organizations being on committees of the service organization, and volunteering time with a local agency. Nurses who prefer to keep their lives private will not be well accepted in the rural community (Long & Weinert, 1992; Hamel-Bissell, 1992). The theme Contextual Knowledge of Patients (Rosenthal, 1996, 2005) identified how nurses must be actively involved in their community. The final theme, professional isolation, is also addressed in the nursing literature. Rural nurses must frequently travel long distances to participate in professional organizational meetings and to attend professional inservices. Nurses who do not attend these meetings may feel isolated in the rural setting. Also the rural nurse may be the only registered nurse on duty in the hospital during her shift and thus may feel isolated (Long & Weinert, 1992). Rural nurses may not feel properly oriented, may not be offered inservices on a regularly preplanned basis and may be limited in their involvement with professional organizations (Boekelheide, 1958). The theme Self Reliance (Rosenthal, 1996, 2005) described the nurses commitment to life long learning. Unique to this study were the findings related to Fluid Role (Rosenthal, 1996, 2005) that included the feelings of team support, rapport, give and take; the implicit trust that develops between team members; and the role transcendence where nurses do tasks Online Journal of Rural Nursing and Health Care, vol. 5, no. 1, Spring 2005 44 of physicians and physicians do tasks of nurses. Expert to novice has not been identified in the literature previously. Subthemes related to the urban nurse transitioning into rural nursing and the surprises they are in for; the feelings of never having enough knowledge; learning things in the midst of the situation, "Trial by Fire"; knowing that you may be the most qualified in a situation; knowing that if you were caught not knowing something that you'll know it next time; and the feelings of confidence gained through certifications such as Advanced Cardiac Life Support and Neonatal Resuscitation courses. In the theme Self Reliance, the nurses' feelings of staying calm; using humor to gain confidence and the feelings associated with being alone, "You're it," are further unique findings. The feelings associated with caring for a known person and how that touches the nurses' heart and soul are the final aspects of this study that are unique in comparison with the literature. DISCUSSION Through stories unique aspects of rural nursing were identified in this study. Stories offer more of a lived experience than do the themes alone. Stories are an important contribution to nursing education and nursing practice. The stories are what the researcher wanted to share with potential new rural nurses. The stories speak to different styles of learners. Some nurses may get more out of themes and subthemes. Others may get more out of the stories. Some readers may need a combination of both to fully understand and appreciate the lived experience of rural nurses. These stories are but one explanation, of course, there may be others. IMPLICATIONS FOR PRACTICE Stories are a way of presenting data that facilitate understanding within the practice setting, and the transcripts revealed a number of implications for nursing practice. Rural nurses involved in this study shared their personal recommendations for urban nurses making the decision to "go rural." The nurses described characteristics of successful rural nurses. Fears and incidents of rule breaking were revealed that have implications for nursing practice. The need for strong teams and allowing for role reversal were explicated. The rewards and benefits of rural nursing were discussed by the rural nurses in the interviews. Support systems were identified that have implications for rural nurse administrators and hospital administrators. Other implications include the introduction of urban nurses to the rewards, complexities and challenges of rural nursing; heightening the sense of choice and decision making regarding moving to and/or working in rural settings; provision of images of rural nursing realities and possibilities; providing an historical context and the formulation of connections with the past; exposing urban nurses to new ideas and perspectives; and reducing urban nursing prejudices and misconceptions regarding rural nursing. Finally, the study's illumination of the uniqueness of rural challenges and rewards may assist with health care reform decision making. Online Journal of Rural Nursing and Health Care, vol. 5, no. 1, Spring 2005 45 RECOMMENDATIONS FOR FUTURE RESEARCH Implications of the study for future research include support for further narrative inquiries and for expansion of the stories to develop rural nursing theory. Gadow (1990) suggests that "The cultivation of personal knowing as a form of inquiry may be the most important contribution of nursing to the human sciences" (p.167). Perhaps this study will encourage others to expand their inquiry into personal knowing and further ask, "What is it like?" regarding other aspects of nursing. The stories (Rosenthal, 1996) may encourage another researcher to study rural nurses using ethnography, phenomenology or grounded theory. This study may encourage others to explore the esthetic pattern of knowing, which allows a greater level of understanding of nursing experiences that are not accessible through other means. The art of nursing can be illustrated best through an esthetic inquiry such as a descriptive narrative, since writing is expressive as well as descriptive. Narrative reflects a special knowing that is from the senses rather than from the intellect. Therefore, some of nursing's most profound experiences can be known only through the sharing of stories, the expression of emotion, and empathy without the restrictions of "scientific" inquiry (Carper, 1978; Sorrell, 1994). Further research into the uncertainty and unpredictability of rural nursing would be helpful to establish a structure that would produce predictability in such an ambiguous set of situations. Perhaps another researcher would be able to determine patterns within the ambiguity-subtle nuances that could actually be forecasted into future events. In future studies another style of interview and/or research methodology could be used. The researcher in this study worked very hard not to tell her own stories in response to the nurse-interviewee stories. It would be an interesting comparison to repeat the study with the researcher engaging in the interviews instead of staying passive. Being more openly empathic might encourage the nurse-participant to share a more threatening story, to further expand on a story, or to offer insight into why treating a patient she knew was difficult for her. Another possibility would be a focus group of rural nurses sharing their stories with the researcher both facilitating the group and actively participating in sharing his or her own stories with the participants. This technique might reveal other stories that are evoked by the researcher's participation. CONCLUSION What stories are you living? Rural nursing offers many unique challenges to the nurse who functions as a generalist in a world of specialist nurses. Rural nurses share stories of shifts where they were providing preoperative care to a patient, then were called in to the operating room to assist with the patient and ended up as the nurse recovering the same patient hours later. These typical rural nursing shifts create struggles, opportunities, and threats to generalist nurses that are specific to the practice of rural nursing. This article compared research in the literature and reported the supporting and unique findings of the author's study (Rosenthal, 1996). One story, “Code Blue Boots,” was shared as an exemplar of rural nursing stories as shared by the interviewees and recreated into stories by the researcher (Rosenthal, 1996). 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