'Staying strong': A constructivist grounded theory of how registered nurses deal with the impact of trauma-related events in rural acute care practice.

AIMS AND OBJECTIVES: This study explored how Registered Nurses (RNs) in rural practice deal with psychologically traumatic events when living and working in the same rural community over time. BACKGROUND: Rural RNs who are exposed to trauma may be at high risk for psychological distress (e.g. secondary traumatic stress, vicarious trauma and post-traumatic stress disorder), in the context of isolated practice and slower emergency response times. DESIGN AND METHODS: Charmaz's constructivist grounded theory methodology was chosen for this qualitative study. Purposeful sampling was used to recruit 19 RNs from six rural acute care hospitals. A total of 33 interviews were conducted with 19 face-to-face initial interviews, 14 follow-up telephone interviews and 14 reflective journals. Adherence to the COREQ EQUATOR guidelines was maintained. RESULTS: Participants were exposed to a multitude of trauma-related events, with their main concern of being intertwined with events for life. They dealt with this by staying strong, which included relying upon others, seeking inner strength, attempting to leave the past behind and experiencing transformational change over time. Being embedded in the community left them linked with these trauma-related events for life. Staying strong was a crucial element to their ability to cope and to face future events. CONCLUSIONS: The psychological implications of trauma-related events when working and living in rural acute care practice settings are significant and complex. Findings highlight the need for organizational support and processes and may contribute to improved psychological services and management practices. RELEVANCE TO CLINICAL PRACTICE: Key learnings were that rural nurses, who live and work in the same community, experience psychological changes over time from traumatic events that stay with them for life; employers fail to recognise the seriousness of this issue and trauma-informed policies with associated resources are lacking.

A framework for nursing practice in rural and remote Canada.

INTRODUCTION: Despite the increased understanding of Canadian rural and remote nursing practice in the past two decades, a synthesis of nursing frameworks to guide practice has been missing from the literature. In this article, the process undertaken to develop a nursing practice framework is described. The purpose of the project was to integrate existing rural and remote nursing evidence into a framework to guide rural nursing practice; inform the actions of rural communities, other health professionals, educators, policymakers and regulators; and support the health of Canadian residents who live in rural and remote areas. METHODS: Two consultants (DE, JK) worked with the Canadian Association for Rural & Remote Nursing (CARRN) Executive to plan and implement a process to develop a rural and remote nursing framework. An external advisory group, representing regulated nurses, and six expert rural nursing researchers were invited to critique project outcomes. A focused international review of the literature was conducted to determine which rural nursing frameworks existed. Electronic database platforms (ProQuest and the Cumulative Index of Allied Health Literature and Medline) were searched, with literature limited to English-only articles. Each article was analyzed to determine relevant key components and elements. RESULTS: The literature review generated 22 full-text articles that were analyzed and synthesized into five main categories: larger society/determinants of health, role of place/the rural or remote context, rural and remote peoples/communities, rural and remote nursing, and health outcomes. A draft document describing the creation of the framework and two different graphic designs of the framework were developed, then sent to the advisory group for critique. All critiques were reviewed and the document was revised as appropriate. The framework design, which used concentric circles to depict relationships between the five identified categories, was selected by a majority of the advisory group reviewers as being representative of their practice and experience. CONCLUSION: It is envisioned that, by using the framework, practicing nurses can identify the tightly woven interconnections within the rural context affecting the health of their clients. Nursing assessments and practice can then be strengthened from consideration of the framework. Nursing programs with dedicated rural nursing content potentially could incorporate the rural and remote nursing practice framework document into classroom and clinical discussions. Due to resource and time restrictions, Indigenous and Francophone nurses were not part of the framework discussions, nor were community members living in rural or remote Canada. Ongoing critique from relevant rural groups will be beneficial for future input and revisions. CARRN is developing a knowledge mobilization strategy to begin this process.

The importance of organizational commitment in rural nurses' intent to leave.

AIMS: To examine determinants of intention to leave a nursing position in rural and remote areas within the next year, for Registered Nurses or Nurse Practitioners (RNs/NPs) and Licensed Practical Nurses (LPNs). DESIGN: A pan-Canadian cross-sectional survey. METHODS: The Nursing Practice in Rural and Remote Canada II survey (2014-2015) used stratified, systematic sampling and obtained two samples of questionnaire responses on intent to leave from 1,932 RNs/NPs and 1,133 LPNs. Separate logistic regression analyses were conducted for RNs/NPs and LPNs. RESULTS: For RNs/NPs, 19.8% of the variance on intent to leave was explained by 11 variables; and for LPNs, 16.9% of the variance was explained by seven variables. Organizational commitment was the only variable associated with intent to leave for both RNs/NPs and LPNs. CONCLUSIONS: Enhancement of organizational commitment is important in reducing intent to leave and turnover. Since most variables associated with intent to leave differ between RNs/NPs and LPNs, the distinction of nurse type is critical for the development of rural-specific turnover reduction strategies. Comparison of determinants of intent to leave in the current RNs/NPs analysis with the first pan-Canadian study of rural and remote nurses (2001-2002) showed similarity of issues for RNs/NPs over time, suggesting that some issues addressing turnover remain unresolved. IMPACT: The geographic maldistribution of nurses requires focused attention on nurses' intent to leave. This research shows that healthcare organizations would do well to develop policies targeting specific variables associated with intent to leave for each type of nurse in the rural and remote context. Practical strategies could include specific continuing education initiatives, tailored mentoring programs, and the creation of career pathways for nurses in rural and remote settings. They would also include place-based actions designed to enhance nurses' integration with their communities and which would be planned together with communities and nurses themselves.

Rural and Remote Registered Nurses' Perceptions of Working Beyond Their Legislated Scope of Practice.

Registered nurses (RNs) enact their scope of practice in everyday practice through the influences of client needs, the practice setting, employer requirements and policies and the nurse's own level of competence (Canadian Nurses Association 2015). A scope of practice is "dynamic and responsive to changing health needs, knowledge development and technological advances" (International Council of Nurses 2013). In Canada, RNs' scope of practice is set out through provincial and territorial legislation and provincial regulatory frameworks, which are broadly consistent, but vary across provinces (Schiller 2015). Provincial and territorial regulatory bodies articulate the RN scope through frameworks that include expected standards as well as, in some jurisdictions, limits and conditions upon practice (British Columbia College of Nursing Professionals 2018), and which are commonly referred to as a licensed or registered scope of practice. Rural and remote practice is starting to be explicitly acknowledged within nurses' legislated scopes of practice through the identification of certified practices for RNs in specific rural and remote practice settings, following approved education (British Columbia College of Nursing Professionals 2018).

Rural and Remote Licensed Practical Nurses' Perceptions of Working Below Their Legislated Scope of Practice.

Over the past two decades in Canada, licensed or registered practical nurses (LPNs) have experienced an extension of their educational preparation and scope of practice. Simultaneously, there has been an increase in the number of LPNs employed in rural and remote communities. These changes have influenced the practice environment and LPNs' perceptions of their work. The aim of this article is to examine what factors predict rural and remote LPNs' perceptions of working below their legislated scope of practice and to explore their perceptions of working below scope. The findings arise from a national survey of rural and remote regulated nurses, in which 77.3% and 17.6% of the LPNs reported their practice as within and as below their legislated scope of practice, respectively. Three factors, age, stage of career and job-resources related to autonomy and control, predicted that LPNs would perceive themselves to be working below their scope of practice. These results suggest that new ways to communicate nurses' scope of practice are needed, along with supports to help rural and remote LPNs more consistently practice to their legislated scope of practice. Without such changes, the LPN role cannot be optimized and disharmony within rural and remote settings may be exacerbated.

Integrating Subjective and Objective Dimensions of Resilience in Fire-Prone Landscapes.

Resilience has become a common goal for science-based natural resource management, particularly in the context of changing climate and disturbance regimes. Integrating varying perspectives and definitions of resilience is a complex and often unrecognized challenge to applying resilience concepts to social-ecological systems (SESs) management. Using wildfire as an example, we develop a framework to expose and separate two important dimensions of resilience: the inherent properties that maintain structure, function, or states of an SES and the human perceptions of desirable or valued components of an SES. In doing so, the framework distinguishes between value-free and human-derived, value-explicit dimensions of resilience. Four archetypal scenarios highlight that ecological resilience and human values do not always align and that recognizing and anticipating potential misalignment is critical for developing effective management goals. Our framework clarifies existing resilience theory, connects literature across disciplines, and facilitates use of the resilience concept in research and land-management applications.

Development and psychometric evaluation of the Job Demands in Nursing Scale and Job Resources in Nursing Scale: Results from a national study.

AIM: To develop and test the psychometric properties of the Job Resources in Nursing (JRIN) Scale and the Job Demands in Nursing (JDIN) Scale. DESIGN: Cross-sectional survey. METHODS: A three-phase process of instrument development and psychometric evaluation was employed: Phase 1: development of a 42-item JRIN Scale and 60-item JDIN Scale through extensive literature review, expert consultation and an iterative content evaluation; Phase 2: pilot survey of 89 nurses and use of item discrimination analysis to estimate the internal consistency reliability of each subscale and reduce the length of each scale; Phase 3: Modified scales were tested in a nationwide survey of 3,822 rural/remote nurses, including use of exploratory factor analysis. RESULTS: The 24 items related to job resources favoured a six-factor structure, accounting for 63% of the variance, Cronbach's alpha 0.88. The 22 items related to job demands favoured a six-factor structure, accounting for 59% of the variance, Cronbach's alpha 0.84.

Perceptions of sense of community and community engagement among rural nurses: Results of a national survey.

BACKGROUND: Variations in rural nurses' sense of community and engagement in rural communities are poorly understood, although there is evidence that these are linked to community cohesion and perceived community resilience. OBJECTIVE: The aim of our research was to develop descriptive profiles of rural nurses who exhibit a sense of community and community engagement at low, average, and high levels, based on occupational, personal, community, and regional characteristics. These results were linked to levels of cohesion and resilience. DESIGN: A survey questionnaire, including established scales, demographic information, and information about rural nursing practice was administered to rural nurses. SETTINGS: Rural communities in all provinces and territories in Canada outside the commuting zone of urban areas with 10,000 or more inhabitants. PARTICIPANTS: Multi-level systematic stratified sampling was employed for the national survey. A subsample of 2116 Registered Nurses, Nurse Practitioners, and Licensed Practical Nurses comprised the participants for this analysis. METHODS: The analysis was conducted in two stages: (1) in the first subset, those (n = 2116) whose primary work community was rural, remote, or rurban with less than 10,000 inhabitants were grouped into a nine-group typology based on low, average, and high tertiles of Psychological Sense of Community and Community Engagement. The second subset (n = 993) represented those in three groups: low-low, average-average, and high-high scores on the two indices. Significant differences between the three groups were identified based on occupational, personal, community, and regional characteristics. Chi Square, ANOVA, and correlation tests were applied as required. RESULTS: Nurses with low scores on both Psychological Sense of Community and Community Engagement were more likely to be from larger communities, single or divorced and living and working in the North. Those with average scores on both scales have been in their nursing positions for more than 20 years, are middle aged and are satisfied with their home community. Nurses in the third group have high scores on both indicators; they are more likely to be from a smaller childhood communities, married or living common-law, and are in the late middle age group. CONCLUSIONS: By focusing on the key variables or traits of nurses, modifiable recruitment and retention practices can be implemented. For example, it is important to recruit nurses who are from smaller communities. Other initiatives for nurses include matching community activities with the age and stage of the family and developing a welcoming strategy for the workplace and community for newly arrived nurses.

Older Adult Caregiving in an Amish Community.

Amish older adults represent a growing and understudied population whose current health practices, interactions with health care systems outside of their community, and care needs are unknown. Limited research exists on why, when, and how Amish older adults and their caregivers experience health care services outside of their family and community. The purpose of the current study was to describe and explore the perspectives of Amish caregivers caring for older adults and their experiences with health care services outside of their community. A qualitative phenomenological research design was used in combination with a community-based participatory framework with caregivers in a small, rural Amish settlement. Amish caregiving of older adults is a complex phenomenon that is influenced by cultural characteristics. Caregivers place significant cultural value on home caregiving, emphasize the experience as a blessing, and relate misunderstandings between themselves and outside health care providers as significant concerns. [Res Gerontol Nurs. 2018; 11(1):29-38.].

Applying cultural safety beyond Indigenous contexts: Insights from health research with Amish and Low German Mennonites.

People who identify as members of religious communities, such as the Amish and Low German Mennonites, face challenges obtaining quality health care and engagement in research due in part to stereotypes that are conveyed through media and popular discourses. There is also a growing concern that even when these groups are engaged in research, the guiding frameworks of the research fail to consider the sociocultural or historical relations of power, further skewing power imbalances inherent in the research relationship. This paper aims at discussing the uses of cultural safety in the context of health research and knowledge translation with groups of people that are associated with a specific religion. Research with the Amish and Low German Mennonites is provided as examples to illustrate the use of cultural safety in this context. From these examples, we discuss how the use of cultural safety, grounded in critical theoretical perspectives, offers new insight into health research with populations that are traditionally labeled as minority, vulnerable, or marginalized, especially when a dominant characteristic is a unique religious perspective.

Exploratory factor analysis and reliability of the Primary Health Care Engagement (PHCE) Scale in rural and remote nurses: findings from a national survey.

Aim The study purpose was to provide evidence of validity for the Primary Health Care Engagement (PHCE) Scale, based on exploratory factor analysis and reliability findings from a large national survey of regulated nurses residing and working in rural and remote Canadian communities. BACKGROUND: There are currently no published provider-level instruments to adequately assess delivery of community-based primary health care, relevant to ongoing primary health care (PHC) reform strategies across Canada and elsewhere. The PHCE Scale reflects a contemporary approach that emphasizes community-oriented and community-based elements of PHC delivery. METHODS: Data from the pan-Canadian Nursing Practice in Rural and Remote Canada II (RRNII) survey were used to conduct an exploratory factor analysis and evaluate the internal consistency reliability of the final PHCE Scale. Findings The RRNII survey sample included 1587 registered nurses, nurse practitioners, licensed practical nurses, and registered psychiatric nurses residing and working in rural and remote Canada. Exploratory factor analysis identified an eight-factor structure across 28 items overall, and good internal consistency reliability was indicated by an α estimate of 0.89 for the final scale. The final 28-item PHCE Scale includes three of four elements in a contemporary approach to PHC (accessibility/availability, community participation, and intersectoral team) and most community-oriented/based elements of PHC (interdisciplinary collaboration, person-centred, continuity, population orientation, and quality improvement). We recommend additional psychometric testing in a range of health care providers and settings, as the PHCE Scale shows promise as a tool for health care planners and researchers to test interventions and track progress in primary health care reform.

"We definitely are role models": Exploring how clinical instructors' influence nursing students' attitudes towards older adults.

The world's population is getting older, which will inevitably cause increased demands for nurses to provide high quality care to this demographic. Attitudes have been shown to influence the quality of care that older adults receive. It is therefore important to gain a better understanding of what influences nursing students' attitudes towards older adults. This article reports on one of three inter-connected research questions of a mixed methods study that explored the relationship between clinical instructors' attitudes and nursing students' attitudes towards older adults. Semi-structured interviews were conducted with 6 clinical instructors and 13 nursing students. Interview data was analyzed using thematic analysis. A conceptual model was developed from the research findings, which revealed that nursing instructors are seen as strong role models for their students, and as role models, they influence students through demonstrations, expectations and support. As a result, nursing students mirror the attitudes of their instructors towards older adults. Findings from this study highlight the strong connection between nursing instructors' and students' attitudes. This has important implications for nursing education including strategies that instructors can employ to enhance students' attitudes towards older adults. Insights from this study also have the potential to improve the quality of care that future nurses provide to older adults.

Nurses who work in rural and remote communities in Canada: a national survey.

BACKGROUND: In Canada, as in other parts of the world, there is geographic maldistribution of the nursing workforce, and insufficient attention is paid to the strengths and needs of those providing care in rural and remote settings. In order to inform workforce planning, a national study, Nursing Practice in Rural and Remote Canada II, was conducted with the rural and remote regulated nursing workforce (registered nurses, nurse practitioners, licensed or registered practical nurses, and registered psychiatric nurses) with the intent of informing policy and planning about improving nursing services and access to care. In this article, the study methods are described along with an examination of the characteristics of the rural and remote nursing workforce with a focus on important variations among nurse types and regions. METHODS: A cross-sectional survey used a mailed questionnaire with persistent follow-up to achieve a stratified systematic sample of 3822 regulated nurses from all provinces and territories, living outside of the commuting zones of large urban centers and in the north of Canada. RESULTS: Rural workforce characteristics reported here suggest the persistence of key characteristics noted in a previous Canada-wide survey of rural registered nurses (2001-2002), namely the aging of the rural nursing workforce, the growth in baccalaureate education for registered nurses, and increasing casualization. Two thirds of the nurses grew up in a community of under 10 000 people. While nurses' levels of satisfaction with their nursing practice and community are generally high, significant variations were noted by nurse type. Nurses reported coming to rural communities to work for reasons of location, interest in the practice setting, and income, and staying for similar reasons. Important variations were noted by nurse type and region. CONCLUSIONS: The proportion of the rural nursing workforce in Canada is continuing to decline in relation to the proportion of the Canadian population in rural and remote settings. Survey results about the characteristics and practice of the various types of nurses can support workforce planning to improve nursing services and access to care.

Experiences of rural and remote nurses assisting with disasters.

BACKGROUND: Globally, disasters are on the rise. Nurses play a significant role in responding to such events but little is known about rural and remote nurses' experiences. METHODS: A national cross-sectional survey of regulated nurses (registered nurses, registered psychiatric nurses, licensed practical nurses and nurse practitioners) in rural and remote Canada provided the data (n=2465) for the logistic regression of predictors of assisting with a disaster event within the last five years. The types of disaster events were also examined and open-ended responses were explored to reveal nurses' perspectives. RESULTS: Nurse type, age, region of employment, employment status, number of rural communities worked, distance to advanced referral centre, remote community, personal-professional boundaries, burnout and work engagement were significant factors related to assisting with a disaster event. Open-ended data alluded to the importance of pre-disaster preparation, and the difficulties experienced when personal-professional relationships are impacted during a disaster. CONCLUSIONS: Nursing education curricula needs to include information about disasters and the nurse's role. Continuing education opportunities and preparation for nurses should be offered in the workplace. Psychosocial supports to assist rural nurses who attend to disasters in their workplace will help them deal with issues such as the blurring of personal-professional relationships.

Development and psychometric evaluation of the Primary Health Care Engagement (PHCE) Scale: a pilot survey of rural and remote nurses.

AIM: To report the development and psychometric evaluation of a scale to measure rural and remote (rural/remote) nurses' perceptions of the engagement of their workplaces in key dimensions of primary health care (PHC). BACKGROUND: Amidst ongoing PHC reforms, a comprehensive instrument is needed to evaluate the degree to which rural/remote health care settings are involved in the key dimensions that characterize PHC delivery, particularly from the perspective of professionals delivering care. METHODS: This study followed a three-phase process of instrument development and psychometric evaluation. A literature review and expert consultation informed instrument development in the first phase, followed by an iterative process of content evaluation in the second phase. In the final phase, a pilot survey was undertaken and item discrimination analysis employed to evaluate the internal consistency reliability of each subscale in the preliminary 60-item Primary Health Care Engagement (PHCE) Scale. The 60-item scale was subsequently refined to a 40-item instrument. FINDINGS: The pilot survey sample included 89 nurses in current practice who had experience in rural/remote practice settings. Participants completed either a web-based or paper survey from September to December, 2013. Following item discrimination analysis, the 60-item instrument was refined to a 40-item PHCE Scale consisting of 10 subscales, each including three to five items. Alpha estimates of the 10 refined subscales ranged from 0.61 to 0.83, with seven of the subscales demonstrating acceptable reliability (α ⩾ 0.70). The refined 40-item instrument exhibited good internal consistency reliability (α=0.91). The 40-item PHCE Scale may be considered for use in future studies regardless of locale, to measure the extent to which health care professionals perceive their workplaces to be engaged in key dimensions of PHC.

Recruitment and Retention in Rural Nursing: It's Still an Issue!

A perennial issue for rural and remote communities in Canada and in other parts of the world is access to a healthcare delivery system including healthcare personnel to provide care to their residents. In total, 18% of Canadians live in rural locations but by proportion have fewer healthcare providers compared with urban settings. Relying on a recently completed documentary analysis of published reports and grey literature on rural and remote nursing practice from Canada and around the world, we recognize that recruitment and retention will be a recurring issue. However, a variety of programs and initiatives have been developed to address this age-old problem. A discussion is provided about educational opportunities, financial incentives and enhanced infrastructure that have been developed to address recruitment and retention challenges. Ongoing evaluations of each of these areas are necessary but require cooperation across provincial and national settings.

Immunization Rejection in Southern Alberta: A Comparison of the Perspectives of Mothers and Health Professionals.

Qualitative grounded theory was used to compare and contrast the understanding and decision-making process of non-immunizing mothers and health professionals' perceptions of these mothers' understanding and decision-making process. The sample comprised 8 mothers with purposefully unimmunized children under the age of 6 years and 12 health professionals. Semi-structured interviews were conducted and the data generated were analyzed using data immersion, memo-writing, and 3 stages of coding. The mothers and health professionals identified similar, interrelated factors influencing the mothers' decision, categorized into 4 groups: emotions, beliefs, facts, and information. Three primary themes were evident: the health professionals emphasized the influence of religion in decision-making to a greater extent than did the mothers, the meaning of evidence appeared to differ for mothers and health professionals, and mothers revealed a mistrust of health professionals. Immunization is a public health issue; collaboration and understanding are necessary to promote positive health outcomes in children.

Les auteures se sont fondées sur une théorie qualitative à base empirique pour comparer l'analyse et la démarche des mères qui décident de ne pas faire vacciner leurs enfants, à l'idée que s'en font les professionnels de la santé. L'échantillon comprend 8 mères ayant délibérément omis de faire vacciner leurs enfants de moins de six ans et 12 professionnels de la santé. Les auteures ont mené des entrevues semi-directives dont les données ont été analysées suivant une méthode fondée sur l'immersion, la prise de notes et trois étapes de codage. Les deux groupes évoquent des facteurs semblables et interdépendants pour expliquer la décision des mères, qu'on peut répartir en quatre catégories: émotions, convictions, faits et information. Trois grands thèmes en ressortent: les professionnels de la santé insistent davantage que les mères sur l'influence de la religion dans la prise de décision; les mères et les professionnels de la santé semblent accorder un sens différent aux données probantes; les mères expriment une certaine méfiance à l'égard des professionnels de la santé. La vaccination est un enjeu de santé publique; la promotion de résultats de santé positifs chez les enfants doit reposer sur la collaboration et la compréhension des enjeux.

Wildfire disasters: implications for rural nurses.

BACKGROUND: As natural disasters are increasing globally, nursing's role in responding to disasters is evolving. Disaster nursing has emerged as a specialty that focuses on the care of groups and communities during disaster response. The role of rural nurses in disasters is less well defined. METHODS: A review of peer-reviewed literature combined with the International Council of Nurses framework of Disaster Nursing Competencies was conducted to understand the roles and functions of nurses in rural areas that experience disasters. The authors' findings from investigating the effects of four wildfires in rural Canadian communities are also discussed. RESULTS: Six major themes derived from our wildfire studies were generated within the context of nursing practice and are useful in the preparation of rural nurses involved in disaster management and recovery. This adds to the current literature which by and large has not addressed nursing in rural catastrophes. CONCLUSION: Well-prepared and educated rural nurses who combine theoretical knowledge with their understanding of a rural community potentially can reduce the impact of a disaster. Other nursing roles include mentoring nursing students in disaster preparation and assisting in initiatives to address community recovery in the aftermath of a disaster.