“We have completed a weather check and are not able to fly at this time. We will re-assess at change of shift in the morning and give you a call back.”
It is three am in our rural hospital; we intubated a patient and need to transfer him to a tertiary care centre. With the support of a virtual critical care consult, we start the interventions that are feasible to perform in our Special Care Unit (the equivalent of a small intensive care unit), but we are unsure when the patient will be transferred out.
I am one of the two registered nurses working and this patient requires one to one care. I am relieved that my partner took the lead in this scenario as she is more experienced, but that leaves me to care for four acutely ill patients by myself while supporting her. The rest of the night passes in a blur of mixing medication drips, monitoring the patient, entering lab work, processing orders, and completing the administrative tasks required to arrange transfer. I feel I am not providing as much care as I should to my other patients, but our priority is managing the most unstable situation.
When we return for our next shift, we learn that our patient passed away shortly after his arrival to the tertiary hospital. The typical follow-up questions raced through my mind. Did the family make it on time to be there when he passed? Would this have happened if we could have transferred him out sooner? Was there something else we could have done? There is no time to debrief the events of the previous night, so we simply prepare for the shift ahead.
Situations like the one I described above are not uncommon in my Northern Ontario hospital. Multiple factors make rural nursing in Canada unique, including the requirement to use a wide range of skills, operate with minimal support and resources, assume numerous roles, and maintain community relationships that can blur personal and professional lines.
While the vast and diverse opportunities draw many nurses to rural practice, this setting is accompanied by stressors that are often overlooked by urban-focused policy makers. Rural practice has many additional associated stressors documented in the literature – including working alone or with few colleagues, waiting for transport teams or managing weather related transport delays, limited continuing education opportunities, and feeling a discrepancy between the perceived ideal of nursing compared to the reality of day to day practice.
Maintaining an adequate nursing workforce is a long-standing challenge in rural communities. For nurses like myself, higher perceived levels of stress at work are a key predictor of intent to leave employment within twelve months. We must therefore ensure that rural nurses are adequately supported in these complex roles in order to improve retention.
From 2003 to 2010, the percent of registered nurses working in rural locations across Canada decreased from 13 per cent to just under 11 per cent. This maldistribution of nurses equates to about 871 registered nurses per 100,000 people in urban centres compared to a ratio of 477 to 100,000 in rural areas.
Nurses are an integral component of the health care system and shortages negatively impact patient outcomes. Given that Canadians residing in rural areas have higher mortality risks associated with respiratory disease, circulatory disease, injuries and suicide, access to quality health care is essential to reducing these health inequities.
Improving rural nurse retention starts with recognizing and mitigating some major stressors unique to rural practice.
At our hospital, a physician is always in the building, but we have limited access to allied health professionals. Services like Telehealth or Virtual Critical Care helps to reduce feelings of isolation and help alleviate the burden of lone decision making as it connects nurses with a network of other clinicians. As a new nurse, I use Telehealth and Virtual Critical Care on multiple occasions and have felt supported by the network of more experienced nurses and allied health professionals that help me manage complex patients more effectively.
Investing in continuing education programs targeted towards rural nurses has also been shown to improve retention. Financial assistance programs that provide travel grants or reimbursement for expenses associated with attending educational events is necessary to improve access to continuing education. In addition, tailoring educational curricula to rural practice settings helps increase nurses’ feelings of competence and confidence. There can also be a role for information and communication technology to improve access to courses – for example, I completed my Canadian Triage and Acuity Scale course via videoconference.
Due to the systemic shortage of rural nurses, many practitioners in rural settings work alone or there are not enough experienced nurses to provide full orientation and adequate support for new nurses. From what I have seen, the lack of support for new staff due to systemic constraints further exacerbates nursing shortages.
Supportive mentorship in nursing will improve transition to rural practice and increase retention. In particular, clinical precepting improves adaptation to new workplaces and strengthens relationships between nurses. Incorporating adequate training and orientation periods for nurses in rural settings is an integral component of retention.
I have experienced both positive aspects and stressors associated with my rural practice. I have found myself in situations where it feels as though I do not have the resources or skills required to manage critically ill patients. But I have also gained valuable professional experience and built meaningful community relationships.
In order to maintain an adequate rural nursing workforce and improve the health of rural Canadians, investments must be made to ensure that the rewarding aspects of rural practice outweigh the stressors.