Besides performing his regular duties as a public health nurse at Creek Nation Community Hospital in the town of Okemah, Okla., Jim Schmidlkofer, BSN, RN, might on any given day start an IV in the surgery and recovery unit, assist in the radiology lab or help treat patients in the emergency room. The hospital is part of a health care system that provides services to American Indians living within the boundaries of the Muscogee (Creek) Nation.

“All of the hospital’s different departments work together,” he says. “We’re like one big family. So many patients and people I work with [are people] I see in the community. We’ve become more like friends.”

This small-town camaraderie is just one of the rewards of working in rural health. The pace may be slower than in a big city, but the variety of the workday and the opportunities to make a significant difference in patients’ lives can’t be beat.

“When I worked in the city, there was a lot of focus on the technical aspects of health care,” Schmidlkofer says. “Here you have time to hold a patient’s hand.”

More minority nurses like Schmidlkofer, who is affiliated with the Potawatomi Nation, are urgently needed in rural areas, where they can play important roles in narrowing health care disparities and improving health outcomes in some of the nation’s most severely medically underserved communities of color.

Troubling Disparities

Health disparities in rural America are so pervasive and troubling that it’s hard to know where to begin talking about them.

“Compared to the general population, rural residents are poorer and older, and these two factors make up the greatest predictors for health status,” says Brock Slabach, senior vice president of the National Rural Health Association in Kansas City, Mo., and a former rural hospital administrator in Mississippi.

People living in rural areas are less likely to have employer-sponsored health insurance or prescription drug coverage, and the rural poor are less likely to be covered by Medicaid benefits. Rural residents are also more likely to lack access to health care providers than urban residents. Many rural areas suffer from a shortage of primary care physicians, specialists, mental health services and nurses. It’s not surprising, therefore, that rural dwellers have higher rates of chronic diseases and poorer overall health than people in big cities.

Diabetes and hypertension, for instance, are rampant in east and central Oklahoma, where the Muscogee Nation Health System operates. Educating patients about disease prevention is a continual challenge for the system’s nurses.

“A lot of people have the [fatalistic] mindset that they’re just going to have diabetes,” says Sheryl Sharber, RN, director of nursing at the Creek Nation Community Hospital. “They figure, ‘Mom had diabetes, Grandma had diabetes–that’s just the way it is.’”

Disparities in health and socioeconomic status between rural and urban residents are especially pronounced among minorities. Although the term “rural poor” tends to invoke images of white Americans living in areas like Appalachia, the reality is that African Americans, Hispanics and Native Americans in rural areas are more likely to be poor than rural whites, according to Minorities in Rural America: An Overview of Population Characteristics, a 2002 report by the South Carolina Rural Health Research Center. And a greater percentage of rural minorities than rural whites live in federally designated Health Professional Shortage Areas.

Geographic isolation and lack of transportation are major barriers to health care for low-income rural residents, says Gloria N. Santos, RN, MS, vice president of patient care services at the 101-bed Feather River Hospital in Paradise, Calif., a small community in the Sierra Nevada foothills 85 miles north of Sacramento. Public transportation is sparse, and there are no sidewalks along main roads. Once a ride becomes available, patients show up at the hospital’s emergency room for treatment.

“Lack of transportation is sometimes the reason our emergency department patients give for not going to their regular doctors’ appointments,” Santos says.
To help improve access to care, the hospital plans to open a new outpatient clinic in Paradise which will be located right across the street from a bus stop.

Rural Cultural Competence

Although careers in rural health care might seem less “glamorous” than working in a large metropolitan area, this field offers tremendous opportunities for minority nurses to make a difference in communities where they are needed most. Demand is especially strong for nurse practitioners, health educators, emergency nurses and nurse managers.

Gloria N. Santos, RN, MSGloria N. Santos, RN, MS

The shortage of minority nurses is more acute in many rural settings because nurses of color are heavily recruited in urban areas, where pay and advancement opportunities are greater. Yet a racially and culturally diverse nursing workforce is just as important in rural areas as it is in urban locations. “It’s vital that the health care professionals mirror the community,” Slabach says.

Minority nurses working in rural health can serve as role models and play a major part in increasing cultural awareness and delivering culturally sensitive care.

“[When you come from the same culture as your patients], you have a better understanding of what they go through and how they were raised,” says Arlene Isham, RN, who works in the family clinic of the Creek Nation’s Okmulgee Indian Health Center in Okmulgee, Oklahoma. “[Because I myself am a member of the Creek tribe], it makes a difference with patients. They’re more at ease. If a patient tells me he was playing stickball and fell and hurt his leg, I know what he’s talking about.”

Isham recalls one day when a patient brought her husband to the clinic because he was delirious. His blood sugar level turned out to be low as a reaction to taking medication on an empty stomach. The man had been on a one-day ceremonial fast, and Isham educated the patient about how to handle his medication when fasting. As a tribal member who also participates in ceremonial fasts, she knew the importance of the ritual from personal experience, which provided a deep understanding of the patient’s need for culturally appropriate care.

“I enjoy working with my own people and trying to raise awareness of their health issues,” she says. “I could go to Tulsa and make more money, but I really like working with my tribe.”

Isham also continues to deepen her knowledge of her cultural heritage. She is learning more of the Creek language, which she did not learn when growing up but is still exclusively spoken by some of the tribe’s elders.

Schmidlkofer says his affiliation with the Potawatomi Nation does not necessarily put him ahead of the learning curve when working with his Creek patients. “Each tribe is unique and a nation unto itself,” he explains. “The most important thing to learn is to be very patient and very respectful when giving information or receiving it.”

Rural Health Research

Rural patients tend to trust health care providers who look like them or whom they’ve known for a long time, says Randy Jones, PhD, MSN, APRN, an assistant professor of nursing at the University of Virginia in Charlottesville. Jones’ research focus is on health disparities in rural minority and vulnerable populations, and he is particularly interested in addressing prostate cancer disparities in African American men, who are 1.5 to two times more likely to develop the disease than white men.

Jones was principal investigator in a study by the university’s Rural Health Care Research Center that found that female family members–wives, sisters or daughters–influenced whether black men decided to get screened for prostate cancer. Trust of the health care system also played an important role. Study participants said they trusted doctors and nurse practitioners with whom they had long relationships.

Arlene Isham, RNArlene Isham, RN

Jones, who has also published research about diabetes among rural African Americans, says health care facilities need to create a welcoming, non-judgmental environment and educate people every time they come through the door about any health issues for which they are at risk.

Establishing trust is also critical for recruiting rural people of color to participate in health care research. Jones points out that many older African Americans remember the infamous Tuskegee syphilis experiment, in which the U.S. Public Health Service conducted research on 399 black men with syphilis from 1932 to 1972. The men were mostly sharecroppers with limited education and were told they were being treated for “bad blood.” In reality, they were given no treatment at all. The scientists planned to study data from the autopsies of the men and essentially left them to deteriorate from the disease. When the media exposed the story in 1972, the experiment finally ended and the men received treatment. By then, 128 of them had died of syphilis or related complications.

Jones, who is African American, says he thinks in some cases his race has helped him establish the trust needed to recruit African American participants into research studies. But most important was his openness and the time he took to explain the intentions of the research. He immersed himself in the community and became acquainted with “gatekeepers,” such as pastors, owners of barbershops and other small businesses, and members of city boards, town councils and the local NAACP.

Filling the Need for Nurses

Increasingly, rural communities are beginning to address the nursing shortage by growing their own RN workforce. Santos, for example, recruits recent nursing graduates from a nearby community college and from a BSN program at nearby California State University, Chico.

Recruiting seasoned nurses is more challenging, she says. Therefore, her hospital is looking at sending newly hired RN graduates to a hospital in Sacramento for a week or two to immerse them in a large-scale critical care setting. This would enable them to see a wider variety of patients and strengthen their skills and confidence in less time than it would take at the rural 12-bed critical care unit.

Santos also participates in a program at CSU Chico that matches minority nursing students with mentors to improve retention. She meets regularly with a Hispanic nursing student to offer encouragement, and she and her mentee have become friends.

Nurses who have found rewarding careers in rural health care say this field offers many advantages, from both professional and personal perspectives. “I think every nurse should work in a rural hospital in the early part of their career, because you have to do a little bit of everything,” says Sharber. “You get a broad exposure.” Although the Creek Nation Community Hospital doesn’t have specialty departments, such as obstetrics or pediatrics, it sees patients of all ages and all disease processes, she adds.

In a rural hospital, emergency nurses are often the first line in caring for patients. “Many times the physicians may not be in house or may be a few miles away,” Slabach says. He also notes that a rural hospital is a more personalized work environment. Nurses and administrators know each other well, and this can lead to greater understanding and flexibility.

Santos grew up in New York and worked in various Adventist Health System hospitals in large cities before moving to her current job at the system’s hospital in Paradise. Her position as vice president of patient care services is equivalent to a chief nursing officer at a larger hospital. But she also oversees other departments besides nursing, including respiratory and cardiology services.

“You’re never at a loss for learning,” she declares. “I just enjoy my work here. I like patient care and I enjoy being able to remove barriers to quality health care.”

Health Disparities in Rural America

• About 20% of the U.S. population lives in rural areas, but only 10% of physicians practice in rural America.

• There are 2,157 Health Professional Shortage Areas in rural America compared to 910 in urban areas.

• Twenty percent of non-metropolitan counties lack mental health services, versus 5% of metropolitan counties.

• Three out of four rural minorities live in Health Professional Shortage Areas, versus three out of five rural whites.

• Rural residents are less likely than urban residents to receive preventive health services, and rural Hispanics are significantly less likely than rural non-Hispanic whites to report receiving preventive medical services.

• Poverty rates are two to three times higher for minorities living in rural areas than for white rural residents. Thirteen percent of rural whites are poor, compared to 34% of African Americans, 25% of Hispanics and 34% of Native Americans in rural areas.

Sources: Rural Healthy People 2010, South Carolina Rural Health Research Center

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