Nurse Navigators - Champions of the National Rural and Remote Nursing Generalist Framework: A solution.

INTRODUCTION: Nurse Navigators were introduced in Queensland, Australia, in 2016. Nurse Navigators coordinate person-centred care, create partnerships, improve care coordination and outcomes and facilitate system improvement, independently of hospital or community models. They navigate across all aspects of hospital and social services, liaising, negotiating and connecting care as needed. People stay with Nurse Navigators for as long as required, though the intent is to transition them from high-care needs to self-management. Nurse Navigators are a working model in rural and remote areas of Queensland. OBJECTIVE: To describe where the rural and remote Nurse Navigator position fits within the Rural Remote Nursing Generalist Framework and to define the depth and breadth of the rural and remote Nurse Navigator's scope of practice. DESIGN: Using template analysis, data from focus groups and interviews were analysed against the domains of the recently released National Rural and Remote Nursing Generalist Framework. Navigators working in rural and remote areas across Queensland Health were invited to an interview (n = 4) or focus group (n = 9), conducted between October 2019 and August 2020. FINDINGS: Rural and remote Nurse Navigators are proficient in all domains of the framework and actively champion for their patients, carers and the communities where they live and work. DISCUSSION: This research demonstrates that rural and remote Nurse Navigators are a working model of advanced nursing practice, acting as 'champions' of The Framework. CONCLUSION: The Nurse Navigator model of care introduced to Queensland exemplifies proficient registered nurse practice to the full extent of their knowledge and skill.

The experiences and perceptions of rural and remote nurses who provide care to pregnant women in the absence of midwives.

INTRODUCTION: Maternity unit closures in rural and remote settings of Australia have left a substantial gap in services for pregnant women. In the absence of midwives, and when women are unable to attend a maternity facility, registered nurses (RNs) are required to fill the void. While maternity education can attempt to prepare RNs for such encounters, there is little documented to suggest it meets all their physical and psychological needs. The existing challenges for health professionals, practising a vast generalist scope of practice while living and working in a rural and remote location, have been well researched and documented. How nurses feel about the expectation that they work outside their scope of practice to provide maternity care in a rural and remote setting in Australia has not been asked until now. This study explores the perceptions and experiences of RNs who find themselves in this situation. METHODS: The study utilised a hermeneutic phenomenological methodology to examine the experiences and perceptions of rural and remote nurses providing care for pregnant women. RNs working in rural and remote health facilities that had no maternity services were recruited by a purposive sampling method. Semistructured conversational interviews were recorded and transcribed verbatim. Data analysis was guided by van Manen's analytical approach. RESULTS: Eight nurses participated, and from the data three themes, each with several subthemes, emerged: 'being-in-the-world of the rural and remote nurse' - described how participants viewed rural and remote nursing as an entity with unchangeable aspects that could not be considered in isolation; 'scope of practice - unprepared or underprepared' described how, despite their existing and extensive nursing skills, participants felt ill-equipped theoretically, practically and mentally to care for pregnant women; 'moral distress' - participants expanded their feelings of unpreparedness to include inadequacy, fear, and appropriateness of care delivery. DISCUSSION: The realism of rural and remote nursing practice demonstrates that at some point in their career, rural and remote nurses will care for a labouring and/or pregnant woman at high risk for complications. Participants in this study appeared open and honest in their interviews, displaying pride at their extensive nursing skills and job satisfaction. However, they were unanimous in their discussions of what being a nurse and providing maternity care in a rural and remote setting meant to themselves and to pregnant women. They suggested care was fragmented and inadequate from a workforce that is inadequately prepared and stressed. CONCLUSION: This study has highlighted another concerning aspect of rural and remote midwifery care - the experiences and perceptions of eight nurses delivering care that has previously been overlooked. The united voice of the RNs in this study warrants a platform to speak from and deserves acknowledgement and attention from government and midwifery policy drivers. These nurses, and the women receiving their care, deserve more.

Addressing the challenges of early career rural nursing to improve job satisfaction and retention: Strategies new nurses think would help.

AIMS: To (a) explore the experiences of early career registered nurses in rural hospitals in Australia and (b) identify strategies they believe would help increase job satisfaction and retention. DESIGN: Qualitative descriptive design. METHODS: Thirteen registered nurses located in outer regional, remote or very remote (herein 'rural') Australian hospitals participated in semi-structured interviews. Participants had graduated from a Bachelor of Nursing program in 2018-2020. Data were analyzed using thematic analysis and an essentialist, bottom-up approach. RESULTS: Seven themes related to the experiences of rural early career nursing: (1) appreciate diverse scope of practice; (2) rewarding sense of community and opportunity to give back; (3) staff support determines the quality of experience; (4) feeling underprepared and the need for ongoing education; (5) diverse views on the optimal length of rotation and level of input into choice of clinical area; (6) difficulty maintaining work/life balance due to work hours and rostering; and (7) lack of staff and resources. Strategies to improve nurses' experiences included: (1) assistance with accommodation and transport; (2) social gatherings to enhance connection; (3) sufficient orientation and supernumerary time; (4) increased frequency of contact with clinical facilitators and multiple mentors; (5) prioritizing clinical education across diverse topics; (6) greater involvement in choice of rotations and clinical areas; and (7) desire for more flexible work hours and rostering. CONCLUSIONS: This study highlighted the experiences of rural nurses and explored their suggestions for how to overcome challenges in their roles. Greater consideration of early career registered nurses' needs and preferences is vital to improving and maintaining a satisfied, dedicated and sustainable rural nursing workforce. IMPACT: Many of the strategies for improving job retention identified by nurses in this study could be actioned at a local level, with little financial or time investment. PATIENT OR PUBLIC CONTRIBUTION: No Patient or Public Contribution.

The impact of rural nursing and midwifery clinical placements from the perspective of health service staff.

OBJECTIVE: To explore the impact of providing nursing and midwifery student placements from the perspective of regional, rural and remote health service staff involved in hosting students. SETTING: Hospital and health services across regional, rural and remote southern Queensland. PARTICIPANTS: Thirty-six nursing and midwifery staff working in clinical and/or management roles who were direct clinical supervisors of students or in leadership positions with responsibility for overseeing and supporting clinical placements. DESIGN: Semi-structured interviews exploring the experiences and perspectives of nursing and midwifery health service staff who support student placements. Data were subject to thematic analysis. RESULTS: Five key themes were identified as follows: (a) bringing new ideas and perspectives, (b) opportunities for development, (c) supporting the future rural workforce (d) impacts on workload and productivity and (e) strategies for balancing supervision. CONCLUSION: The results indicate that there are a range of perceived benefits and challenges of providing nursing and midwifery student placements within regional, rural and remote settings. The findings also indicate that there are opportunities to further support rural health services to optimise the positive impacts and mitigate the challenges of providing placements. To do so requires collaboration between health services and education providers to allocate students appropriately to health services and support health service staff.

Testing telediagnostic obstetric ultrasound in Peru: a new horizon in expanding access to prenatal ultrasound.

BACKGROUND: Ninety-four percent of all maternal deaths occur in low- and middle-income countries, and the majority are preventable. Access to quality Obstetric ultrasound can identify some complications leading to maternal and neonatal/perinatal mortality or morbidity and may allow timely referral to higher-resource centers. However, there are significant global inequalities in access to imaging and many challenges to deploying ultrasound to rural areas. In this study, we tested a novel, innovative Obstetric telediagnostic ultrasound system in which the imaging acquisitions are obtained by an operator without prior ultrasound experience using simple scan protocols based only on external body landmarks and uploaded using low-bandwidth internet for asynchronous remote interpretation by an off-site specialist. METHODS: This is a single-center pilot study. A nurse and care technician underwent 8 h of training on the telediagnostic system. Subsequently, 126 patients (68 second trimester and 58 third trimester) were recruited at a health center in Lima, Peru and scanned by these ultrasound-naïve operators. The imaging acquisitions were uploaded by the telemedicine platform and interpreted remotely in the United States. Comparison of telediagnostic imaging was made to a concurrently performed standard of care ultrasound obtained and interpreted by an experienced attending radiologist. Cohen's Kappa was used to test agreement between categorical variables. Intraclass correlation and Bland-Altman plots were used to test agreement between continuous variables. RESULTS: Obstetric ultrasound telediagnosis showed excellent agreement with standard of care ultrasound allowing the identification of number of fetuses (100% agreement), fetal presentation (95.8% agreement, κ =0.78 (p < 0.0001)), placental location (85.6% agreement, κ =0.74 (p < 0.0001)), and assessment of normal/abnormal amniotic fluid volume (99.2% agreement) with sensitivity and specificity > 95% for all variables. Intraclass correlation was good or excellent for all fetal biometric measurements (0.81-0.95). The majority (88.5%) of second trimester ultrasound exam biometry measurements produced dating within 14 days of standard of care ultrasound. CONCLUSION: This Obstetric ultrasound telediagnostic system is a promising means to increase access to diagnostic Obstetric ultrasound in low-resource settings. The telediagnostic system demonstrated excellent agreement with standard of care ultrasound. Fetal biometric measurements were acceptable for use in the detection of gross discrepancies in fetal size requiring further follow up.

The Practice of Home Visiting by Community Health Nurses as a Primary Healthcare Intervention in a Low-Income Rural Setting: A Descriptive Cross-Sectional Study in the Adaklu District of the Volta Region, Ghana.

BACKGROUND: Home visit is an integral component of Ghana's PHC delivery system. It is preventive and promotes health practice where health professionals render care to clients in their own environment and provide appropriate healthcare needs and social support services. This study describes the home visit practices in a rural district in the Volta Region of Ghana. Methodology. This descriptive cross-sectional study used 375 households and 11 community health nurses in the Adaklu district. Multistage sampling techniques were used to select 10 communities and study respondents using probability sampling methods. A pretested self-designed questionnaire and an interview guide for household members and community health nurses, respectively, were used for data collection. Quantitative data collected were coded, cleaned, and analysed using Statistical Package for Social Sciences into descriptive statistics, while qualitative data were analysed using the NVivo software. Thematic analysis was engaged that embraces three interrelated stages, namely, data reduction, data display, and data conclusion. RESULTS: Home visit is a routine responsibility of all CHNs. The factors that influence home visiting were community members' education and attitude, supervision challenges, lack of incentives and lack of basic logistics, uncooperative attitude, community inaccessibility, financial constraint, and limited number of staff. Household members (62.3%) indicated that health workers did not adequately attend to minor ailments as 78% benefited from the service and wished more activities could be added to the home visiting package (24.5%). CONCLUSION: There should be tailored training of CHNs on home visits skills so that they could expand the scope of services that can be provided. Also, community-based health workers such as community health volunteers, traditional birth attendants, and community clinic attendants can also be trained to identify and address health problems in the homes.

Experiences of Western Australian rural nursing graduates: A mixed method analysis.

AIMS AND OBJECTIVES: To determine whether the current rural graduate programmes in Western Australia adequately support new graduate nurses transitioning into practice. BACKGROUND: Graduate nurse's transition to employment is a time of significant change and challenge, often resulting in periods of transition shock. These challenges are magnified in rural areas where graduates have to relocate to commence their career with limited rural nursing experience. Graduate programmes were developed to smooth the transition for university trained bachelor's degree registered nurses into the workforce. Supportive graduate nursing programmes are essential for enabling transition to practice and reduce attrition rates. DESIGN: Longitudinal convergent mixed method parallel design was informed by Duchscher's transition stage model. METHOD: Thematic analysis was applied to all interviews. COREQ checklist was completed. Descriptive statistics and content analysis were used to analyse the survey responses. RESULTS: New graduates cycled through both transition shock and honeymoon periods on commencement of employment, reporting high levels of satisfaction in simultaneity with signs of transition shock. Satisfaction dropped within 7 months indicating a transition crisis before an adjustment period occurred at the end of their graduate year. Limited resources were highlighted as obstacles to providing adequate support to rural graduate nurses. CONCLUSION: The honeymoon stage of transition co-existed with transition shock at the commencement of graduate programmes, which may obscure the need for continuing adequate support. Inadequate and/or a lack of preceptorship was evident throughout the Western Australian rural graduate programmes. Graduate programmes need to be structured but flexible to allow for individual differences in graduates' and clinical contexts. RELEVANCE TO CLINICAL PRACTICE: Structured but flexible graduate programmes allow for individual differences in graduates and clinical situations. New graduate nurses would benefit from a break midway through their graduate year to assist and overcome the transition crisis stage. Education of nurses undertaking the preceptor role is required to deliver adequate support to graduate nurses and decrease transition shock.

Conscientious objection to medical assistance in dying in rural/remote nursing.

In 2016, the Supreme Court of Canada legalized medical assistance in dying in Canada. Similar to jurisdictions where this has been a more long-standing option for end-of-life care, the Supreme Court's decision in Canada included a caveat that no healthcare provider could be compelled to participate in medical assistance in dying. The Canadian Nurses Association, in alignment with numerous ethical guidelines for healthcare providers around the globe, maintains that nurses may opt out of participation in medical assistance in dying if they conscientiously object to this procedure. The realities of implementing medical assistance in dying are still unfolding. One area that has received little attention in the literature thus far is the ability of nurses who aid with, rather than administer, medical assistance in dying to conscientiously object. This is particularly significant in rural and remote areas of Canada where geographic dispersion and limited numbers of nursing staff create conditions that limit the ability to transfer care or call on a designated team. Exercising conscientious objection to medical assistance in dying in rural and remote areas, by way of policies developed with an urban focus, is one example of how the needs of rural nurses and patients may not be met, leading to issues of patient access to medical assistance in dying and retention of nursing staff. To illustrate the complexities of nurses' conscientious objection to medical assistance in dying in a rural setting, we apply an ethical decision-making framework to a hypothetical case scenario and discuss the potential consequences and implications for future policy. Realizing that conscientious objection may not be a viable option in a rural or remote context has implications for not only medical assistance in dying, but other ethically sensitive healthcare services as well. These considerations have implications for policy in other jurisdictions allowing or considering medically assisted deaths, as well as other rural and remote areas where nurses may face ethical dilemmas.

Building a rural workforce through identifying supports for rural, mature-aged nursing and allied health students: A systematic scoping review.

INTRODUCTION: There is a long-standing undersupply of nursing and allied health professionals in rural Australia. Rural, mature-aged people form an untapped section of rural communities that could help to address these workforce needs. There is little understanding of the supports required to assist rural, mature-aged nursing and allied health students to complete their studies and enter the rural health workforce. OBJECTIVE: To scope factors influencing rural, mature-aged nursing and allied health students' ability to access, participate, and succeed in higher education. DESIGN: A scoping review of the international rural nursing and allied health and education literature was undertaken. Five databases (CINAHL Complete, MEDLINE, Education Resources Information Center [ERIC], Embase, and Education Research Complete), key peer-reviewed journals, and Australian grey literature were searched. FINDINGS: Fourteen articles were included in the review. Ten studies described rural, mature-aged nursing and allied health student characteristics, 6 described barriers to students participating and succeeding in higher education, and 4 described student supports. DISCUSSION: This review found limited evidence to guide higher education providers in attracting, supporting and retaining rural, mature-aged nursing and allied health students. In particular, evidence of student supports is required beyond those manifested by students themselves or their family, to include offerings from university and government sources. CONCLUSION: Substantially more research attention is needed to understand the experiences of rural, mature-aged nursing and allied health students, and supports required for this cohort to access, participate and successfully complete higher education.

Increasing rural nurses' awareness of a statewide health information resource: an educational outreach initiative.

BACKGROUND: HEALWA is an online library of evidence-based health information resources that are available to Washington state health practitioners. To increase awareness and use of HEALWA among health practitioners in rural areas, the National Network of Libraries of Medicine Pacific Northwest Region and Washington State University Spokane co-funded an outreach librarian position to provide instruction on using HEALWA. CASE PRESENTATION: After attempts at frequent in-person workshops failed due to lack of attendance, a one-hour-long webinar targeted at rural nurses was developed to be delivered once a month. These webinars introduced participating health professionals to HEALWA, including how to set up their access and how to navigate the resource. To accommodate the busy schedules and different learning styles of the target audience, the workshops occurred both as monthly webinars and in-person, when available, in addition to an online self-guided tutorial. Continuing education credit was obtained through the Washington State Nurses Association, and a partnership with the Washington State Nursing Commission improved promotion of the webinars. Evaluations for both the webinars and workshops have been largely positive. CONCLUSIONS: The webinar series, coupled with in-person workshops and an online tutorial, reached nurses in rural areas of Washington state to increase awareness of HEALWA. To further facilitate access to HEALWA instruction, a recorded version of the live webinar is in development.

Communication tools and sources of education and information: a national survey of rural and remote nurses.

OBJECTIVE: This study examined accessibility of communication tools in the workplace, use of education to update nursing knowledge, and use of information to make specific decisions in practice among registered nurses (RNs) and licensed practical nurses (LPNs) in rural and remote communities in Canada. METHODS: Data were analyzed from the cross-sectional survey, "Nursing Practice in Rural and Remote Canada II," of regulated nurses practicing in all provinces and territories of Canada. Data were collected from April 2014 to August 2015. RESULTS: The survey was completed by 3,822 of 9,622 nurses (40% response), and the present analysis was conducted with a subsample of 2,827 nurses. High-speed Internet was the most accessible communication tool, and nurses used "online/electronic education" more often than "in-person education" to update their nursing knowledge. Internet searches were used more often than several other online/electronic sources to inform decision making. Compared to LPNs, RNs reported greater workplace access to most communication tools and greater use of online/electronic education as well as information sources in online/electronic and print formats. Compared to nurses in community-based health care and hospital settings, nurses in long-term care settings reported lower access to most communication tools, lower use of online/electronic and in-person education, and lower use of online/electronic information. CONCLUSIONS: Access to continuing education and up-to-date information is important for effective patient care. This study points to a need for further research on the continuing education and information needs of rural and remote RNs and LPNs, and on their capacity to incorporate and apply new knowledge in practice.

When Disaster Strikes in Rural America-Call the Midwife!

Midwives can play a critical role in emergency preparedness and response. Rural areas have unique disaster preparedness needs but receive less attention than urban centers. Childbearing women and infants are particularly affected during disasters. Midwives are well positioned to coordinate disaster preparedness training and response to optimize the health of women and infants in rural areas.

"Keeping You in the Know": The Effect of an Online Nursing Journal Club on Evidence-Based Knowledge Among Rural Registered Nurses.

The purpose of this research study was to promote and evaluate clinical scholarship in rural registered nurses through the dissemination of evidence-based practice findings via the development and implementation of an online nursing journal club. A simple pretest-posttest design was selected to implement this project. Along with descriptive data, survey data were analyzed using a paired t test. A convenience sample from a rural university nursing alumni email database spanning 2010-2011 and 2014-2016 was invited to participate. Three articles, one each month, were presented on the journal club Web site. Along with the 10-question pretest and posttest, the Evidence-Based Practice Questionnaire survey was completed after the third article posttest. By the end of the third month, 37 participants completed all three articles and Evidence-Based Practice Questionnaire survey. The results of the paired t tests all revealed a significant mean difference increase in knowledge from pretest to posttest (P < .05). In addition, the Evidence-Based Practice Questionnaire survey revealed that participants felt "good" about their knowledge of evidence-based practice related to areas such as reviewing practice skills, ability to identify gaps in practice, ability to analyze critical evidence, ability to determine how valid material is, and ability to apply information to individual cases.

Collaborative Rural Nurse Peer Review: A Quality Improvement Project.

BACKGROUND: Peer review is an essential element of professional nursing practice. LOCAL PROBLEM: Implementing nursing practice peer review is a challenge in any organization; some characteristics of small and rural hospitals can make the task especially daunting. METHODS: A team of nursing leaders and staff nurses from rural and critical access hospitals within 1 health care system was formed to make recommendations about implementing nursing practice peer review in the small rural facilities. Barriers included limited numbers of nurse reviewers by nursing specialty and inherent bias of reviewers due to personal knowledge of cases and nurses involved. INTERVENTIONS: A collaborative rural nursing practice peer review council was created, with staff nurse and leader representation from 6 geographically distinct facilities. RESULTS: The rural collaborative council has developed processes for case referral, reviewer assignment, investigation, and scoring founded on Just Culture principles. Satisfaction among staff nurses, reviewers, and Chief Nursing Officers has been high. CONCLUSIONS: Barriers to implementation of nursing practice peer review in rural hospitals can be mitigated through a collaborative approach, resulting in efficient and effective processes for small, rural, and geographically distinct hospitals.

Diabetes screening in pregnancy failing women in rural Western Australia: An audit of oral glucose tolerance test completion rates.

OBJECTIVE: To quantify screening rate for gestational diabetes mellitus and completion of oral glucose tolerance test in rural and remote Western Australia. DESIGN AND PARTICIPANTS: Retrospective audit of 551 antenatal records from women of 16 years and older without pre-existing diabetes and with singleton pregnancies delivered in 2013. MAIN OUTCOME MEASURES: Number of women recorded screened for gestational diabetes mellitus in second or third trimester using oral glucose tolerance test or other tests; gestational diabetes mellitus rate. RESULTS: Only 278 (50.5%) women were screened with oral glucose tolerance test; 113 (20.5%) had no record of any screening related to gestational diabetes mellitus. In a nested mixed-effects logistic regression model, women with a previous gestational diabetes mellitus diagnosis, two or more risk factors (excluding ethnicity) or high-risk gestational diabetes mellitus ethnicity other than Australian Aboriginal were more likely to be screened, while Australian Aboriginal women were less likely to be screened with oral glucose tolerance test. Clinicians reported patient and clinician factors and logistical difficulties as reasons for the oral glucose tolerance test not being completed at their site. Of those screened with oral glucose tolerance test, a high rate of gestational diabetes mellitus was diagnosed (14.7% versus Western Australia state-wide average of 7.4%). CONCLUSION: Adherence to oral glucose tolerance test screening in rural Western Australia is inadequate for effective screening for gestational diabetes mellitus. Screening was not acceptable or available for a significant proportion of women at risk. Efforts to improve oral glucose tolerance test adherence and exploration of alternative gestational diabetes mellitus screening strategies are required.

What are the support needs of nurses providing emergency care in rural settings as reported in the literature? A scoping review.

INTRODUCTION: Australia is a country with a rich history, and unique geography, with nearly one-third of its population living in rural areas. This presents certain challenges to nurses providing emergency care in these regions, as their support needs are different from their urban counterparts. This systematic scoping review aims to determine the support needs of these nurses providing emergency care in rural settings as reported in the literature. Many other countries have large rural populations, and relevant international literature will be considered to allow discussion of the key issues and recommendations for the future of the rural nursing workforce. METHODS: Databases searched included PubMed, Cochrane database, ERIC and Google Scholar using keywords 'rural', 'nurse', 'emergency', 'support needs', 'challenges' and 'Australia', and research from 2012 onwards was examined for relevance. Earlier seminal texts were also included. Reference lists of retrieved articles were searched and citations explored for further relevant research material. The Joanna Briggs Institute's scoping review framework was used. The primary focus was on peer-reviewed research with supplementary grey literature (eg materials and research produced by organisations outside of the traditional publishing channels). International material was used where relevant. RESULTS: Analysis of the literature revealed that the four main areas of concern were a lack of effective graduate training programs or the availability of mentors, poor recruitment and retention numbers, a need for better recognition for the extended role of the rural nurse as a 'nurse generalist' or rural 'specialist' and poor access to role-specific ongoing education. These areas of concern were exacerbated by geographic isolation and a perceived lack of funding. CONCLUSION: Delivering appropriate evidence-based education to this isolated practice community is vital for safe patient care and improves rural nurse satisfaction and retention. There were gaps in current knowledge, and the body of research to date lacks information on the work of emergency nurse practitioners in the rural context, the effectiveness of graduate mentorship programs and the psychosocial aspect of the rural role. Recommendations are for improved role-specific ongoing education and the availability and development of graduate mentoring programs. Further input into recruitment and retention is required, and further research on the needs of rural emergency nurses is recommended.

Multi-Patient Rabies Exposure on a Colorado River Rafting Expedition: Urgent vs. Emergent Transport Decision Making in an Austere Setting.

We present a case of rabies exposure on a private river rafting trip on Grand Canyon National Park's Colorado River. Five individuals were exposed to an erratically acting bat; one of the individuals sustained a direct bite to the upper lip while sleeping. This case illustrates the challenges of austere medical care and evacuation in remote conditions while highlighting the importance of risk mitigation considerations in all austere situations.

An integrative review of rural and remote nursing graduate programmes and experiences of nursing graduates.

AIMS AND OBJECTIVES: To examine international studies that specifically focus on transition to practice for graduate registered nurses in rural and remote areas. BACKGROUND: Supportive graduate nursing programmes are essential for enabling nursing graduates' transition to practice and reducing attrition rates. Literature examining support measures for nursing graduates within metropolitan areas is abundant. However, there is a paucity of evidence on effective graduate programmes for rural and remote-based nursing graduates. DESIGN: A systematic approach was used to identify robust research within appropriate electronic databases. METHOD: Eligible articles were critically reviewed using the Mixed Method Appraisal Tool critical appraisal tool. Eligible articles were thematically analysed using the Braun and Clark approach. RESULTS: Eight articles met the selection criteria for inclusion. Findings revealed that while most graduate nurses survived the transition process, they often felt overwhelmed and abandoned with intense feelings of frustration. Many suffered transition shock and did not feel ready for the role. Socialisation of graduates to the clinical environment was lacking. Support offered in many graduate programmes was ad hoc and unstructured. Senior staff were inadequately supported in their roles as preceptors to assist with the transition. Critical support measures recommended included both debrief sessions and regular one-on-one support. CONCLUSIONS: Graduate programmes need to be structured yet flexible to accommodate the needs of rural and remote nurse graduates. Graduates need to be transitioned into practice with decremental support processes for both workloads and education. Preceptors require education on how to mentor before they can provide the appropriate support for graduates. Without these measures in place, a decrease in transition shock may not be possible. RELEVANCE TO CLINICAL PRACTICE: Graduate programmes need to be structured yet flexible, including assistance with both clinical skills and socialisation. Senior staff require education before they can adequately support new graduates.

A practice model for rural district nursing success in end-of-life advocacy care.

AIM: The development of a practice model for rural district nursing successful end-of-life advocacy care. BACKGROUND: Resources to help people live well in the end stages of life in rural areas can be limited and difficult to access. District nurse advocacy may promote end-of-life choice for people living at home in rural Australia. The lack of evidence available internationally to inform practice in this context was addressed by exploratory study. METHOD: A pragmatic mixed method study approved by the University Faculty Ethics Committee and conducted from March 2014 to August 2015 was used to explore the successful end-of-life advocacy of 98 rural Australian district nurses. The findings and results were integrated then compared with theory in this article to develop concepts for a practice model. RESULTS: The model illustrates rural district nurse advocacy success based on respect for the rights and values of people. Advocacy action is motivated by the emotional responses of nurses to the end-of-life vulnerability people experience. The combination of willing investment in relationships, knowing the rural people and resources, and feeling supported, together enables district nurses to develop therapeutic emotional intelligence. This skill promotes moral agency in reflection and advocacy action to overcome emotional and ethical care challenges of access and choice using holistic assessment, communication, organisation of resources and empowering support for the self-determination of person-centred end-of-life goals. Recommendations are proposed from the theoretical concepts in the model. LIMITATIONS: Testing the model in practice is recommended to gain the perceptions of a broader range of rural people both giving and receiving end-of-life-care. CONCLUSION: A model developed by gathering and comparing district nursing experiences and understanding using mixed methods and existing theory offers evidence for practice of a philosophy of successful person-centred advocacy care in a field of nursing that lacks specific guidance.

Rural Nurse Managers' Perspectives into Better Communication Practices.

The aim of this qualitative study was to describe the communication perceptions of nurse managers in rural areas. Prior research in tertiary settings was the impetus for studying viewpoints in other settings. Grounded theory methods were used to collect and analyze interview data with nine managers from regional, critical access hospitals, and home health settings in central Pennsylvania. Nurse Managers associated successful communication with job satisfaction, work efficiency, and employee retention. Circumstances influencing communication involved discussion tones, techniques, resources, and environmental factors. Recommended techniques included regular conversations, diverse messaging, and conferencing huddles to improve information dissemination and workflow in rural settings.