Every workplace has its challenges. But, on the flip side, each has its advantages as well. We asked Beverly A. Ely, APRN, FNP-C, who works as a Family Nurse Practitioner in Harrogate, Tennessee, about what it’s like to see patients in a rural area.
Beverly A. Ely, APRN, FNP-C
What kind of work do you do?
I currently am a Family Nurse Practitioner and work with Lincoln Memorial University/DeBusk College of Osteopathic Medicine. We have 2 clinic locations that serve the University and the public. In the clinic, I see patients of all age groups from newborns to the elderly.
Working in a rural area is quite different from what most nurses do. Have you worked in a more urban or suburban area before this? If so, how does working in a rural area differ from those places?
My career spans over many decades and regions. I began a career in nursing in the late ‘80s. I graduated from Lincoln Memorial University with a degree as an Associate Nurse. I chose to begin my nursing career in Knoxville, TN and commute back and forth. Working in a suburban area, I encountered larger volumes of patients in which needs were very different than those in an urban location.
The urban area is different than the area where I first began my career. Coming back to it was a different experience, but one that has proven to be the most rewarding. I help them meet the simplest of everyday needs and assist them with coping skills to understand a diagnosis—this is rewarding. That is what I cherish about rural health and the people of the Appalachian area. I can now say that I can give back and serve the people that have given me so much.
Why did you choose to work in a rural setting? What kinds of patients do you tend to see? How are they different from those you saw in a more urban setting?
I chose to work and serve in the rural area of Appalachia because the needs are so great. I completed 29 years as a suburban nurse and saw many different classes for people. The common denominator for both is survival.
What have you learned from working as a nurse in a rural area?
I have learned to be patient and compassionate. I have learned that there is very little that we truly need in order to survive.
What are the biggest challenges of working in a rural setting?
The biggest challenge is compliance and understanding of their illness.
What are the greatest rewards?
Seeing people feel better and the smiles on their faces.
What would you say to someone considering moving to work in a rural area? What do they need to be willing to do or deal with?
I would voice that rural health is the most rewarding field that you can chose. It requires you to have compassion and patience.
Is there anything else about working in a rural area that is important for people to know?
Yes. Do I plan to continue here? The answer would be YES. It is the most rewarding of my 30 years as a nurse that I could have ever imagined. I’m compassionate and love the people of Appalachian and desire to see them live life to the fullest.
Many rural and urban communities face a shortage of qualified health professionals to meet the population’s needs. These underserved communities face unique challenges and nurses working in these areas need unique skills to meet those challenges.
What’s it like working as a nurse in an underserved community? What skills and qualities should nurses have in order to succeed in this area?
Amanda Buccina, BSN, is an RN for the Street Outreach Nurse Program for WellSpace Health in partnership with Sutter Health. She says that nurses should have a passion for working with underserved communities, possess strong coping skills, and understand the importance of self-care. She also notes that nurses working with underserved populations should be interested in and willing to make deep connections with people from all walks of life.
If you are thinking about pursuing a career as a nurse in an underserved area, these tips will help you succeed.
Understand the Culture
Erin G. Cruise, PhD, RN, NCSN, associate professor, Radford University School of Nursing, who has worked in public health and school nursing in rural areas and small hospitals for more than 10 years, says that nurses wishing to work in rural, underserved areas, and/or with vulnerable populations need to have a good foundation in clinical skills, organization, and communication. Cruise also emphasizes the importance of understanding the cultural dynamics of the community.
“Small hospitals and community agencies generally found in rural areas are often part of a close-knit community,” says Cruise. “People know each other and they want to know the nurse caring for them on a more personal level.”
Cruise says that new rural nurses can be taken aback by the expectation of openness. “Some nurses are not comfortable with having their personal lives become an open book,” she says. “It can be a thin line between patients just being friendly and curious and the nurse feeling that he/she lacks the privacy and anonymity found when working in larger agencies and big cities.”
People in rural or small town communities are also more likely to ask questions about private health information regarding their neighbors. “While neighborly concern and curiosity are usually quite innocent, nurses in these settings must be very careful and familiar with HIPAA and their own hospital or agency policies on confidentiality to avoid sharing that information inappropriately,” warns Cruise.
Build Strong Patient Relationships
A typical day for Buccina includes walking and driving around Sacramento, CA, meeting with patients on the streets, without the convenience of a full clinical facility. She works hard at building trust with her patients.
“A lot of my job is relationship building,” says Bucinna. “I work to build trust and rapport with my clients so even if they don’t need me in that exact moment, we have a relationship and familiarity with one another. I’m there when clients do want and need support, like medical advice, an advocate at a doctor’s appointment, help getting into an alcohol or drug rehab program, or just general wound care.”
Provide Judgment-Free Care
Cruise notes that many vulnerable people lack the resources that allow them to manage their health effectively, and nurses should be prepared to meet these patients right where they are, without judgment.
“They may have low literacy, live in poverty, live in environments that are polluted, run down, or crime-ridden; and work in jobs with low pay and dangerous conditions,” says Cruise. “People in these situations will pick up on a disapproving attitude by the nurse and shut down, shut the nurse out, and be less likely to follow his or her health care directions. Nurses should adopt a caring approach. While not condoning negative or criminal behaviors, accepting clients as they are and demonstrating concern for their health and well-being are more likely to motivate them to listen to the nurse’s advice and make positive changes.”
Jan Jones-Schenk, national director of Western Governors University’s (WGU) College of Health Professions and chief nursing officer for WGU, encourages nurses working with underserved populations to avoid making assumptions about their patients.
“Don’t label or assume individuals who don’t follow prescribed advice are non-compliant,” says Jones-Schenk. “There may be financial, social, physical, or cultural reasons why individuals do not follow the advice given. In such cases, the problem can easily be that it’s the wrong advice for that patient. Taking a patient-centered approach means the advice given has to be something the patient thinks makes sense too.”
Jones-Schenk advises nurses to remain open to listening carefully to understand the barriers and limitations individuals may be facing.
Gain Mental Health Experience
Buccina says that her best advice for nurses considering working in underserved communities is to gain some experience in mental health in order to understand human growth and development from a psychological perspective, and to become well-versed in social issues in order to avoid judgment and approach the population from a place of knowledge and compassion.
Finally, Cruise advises nurses working with vulnerable populations and/or in rural areas to find the time and space to take care of themselves.
“Because these communities are close-knit and vulnerable populations, they may mistake the nurse’s caring approach for a desire to have a more personal relationship. The nurse will have to set boundaries in a way that is kind and not perceived as rejecting of the client, yet allows the nurse to be seen as a professional and not just a friend,” says Cruise.
Everyone knows that cities have a strong need for medical professionals. After all, we’ve all seen ER. On television shows, city emergency rooms (and hospitals in general) are always understaffed, with doctors and nurses and other medical professionals scrambling to keep up with an ever-increasing patient load. All of this might make for interesting drama, but the truth is that rural areas have a far greater shortage of medical personnel than urban areas.
In addition, factors such as a lower rate of employer-provided health care, a higher poverty rate, and a greater proportion of elderly residents add up to a health care crisis in rural America . Enter the National Rural Health Association (NRHA). Headquartered in Kansas City , Mo. , the NRHA is working to improve the “health and health care of rural America .” Through legislative initiatives, education, communication and research, NRHA has made some significant progress since it was established in 1977. But there is still a long way to go. Diversity: Allied Health Careers talked with NRHA’s executive director, Steven Wilhide, to learn a bit about the association’s present initiatives and plans for the future.
Can you tell us a little bit about your background? When did you first start working for NRHA?
“After receiving my bachelor’s degree from Frostburg State College in Maryland , I became a VISTA volunteer and served in Cherokee, N.C. In 1967 I was drafted into the Army. After a tour in Vietnam , I attended the University of Maryland School of Social Work where I received a Master of Social Work in community organization. After working in a rural community health center in Wilkes Barre, Pa., I accepted a fellowship to the University of Pittsburgh where I received a Master of Public Health in 1976. In the fall of 1976, I accepted a position as executive director of the Southern Ohio Health Services Network (SOHSN), a newly formed community health center serving four Appalachian counties. Today SOHSN operates 12 primary care clinics with a staff of over 250 and a budget of over $17 million. In January 2002, I came on as the Executive Director of the National Rural Health Association.”
What programs and initiatives does NRHA currently have in place to recruit allied health professionals to rural communities?
“NRHA started a Migrant Health Care Fellowship Program to train allied health professionals to work with rural underserved populations; primarily migrant and seasonal farm workers. This program is now being administered by the Migrant Clinicians Network. NRHA has also started a job bank that currently targets opportunities for administrators seeking positions in rural community health centers. However, we plan on expanding this job bank to include positions for allied health professionals later this year. You can find this resource on our Web site (www.nrharural.org) by clicking on the ‘Rural Health Job Bank’ link.”
What is the NRHA doing to help improve the quality of health care in rural America ?
“NRHA has many legislative and policy initiatives to improve the quality of health care in rural America . The NRHA’s mission is ‘to assure quality, equity, and access for all rural Americans.’ Our policy and legislative positions are too exhaustive to go into detail here, but you can view them all on our Web site. We also work to provide assistance to our members on a variety of recruitment and retention (R/R) issues through advocacy work in Washington, D.C. , disseminating R/R research, and providing an opportunity to learn about R/R initiatives from peers at our annual conference.
“In addition, we are involved in efforts to inform rural residents that local care is high quality care. When rural residents start bypassing the local hospital for their health care, the economic impact of those health care dollars leaving the community can have adverse affects on hospital resources.”
What is the quality of the health care provided to minority populations in rural areas? What is NRHA doing to help improve the quality of health care received by rural minority populations?
“Minority populations in both rural and urban areas have greater problems accessing health care services. They receive fewer preventative services and have greater disparities in health outcomes than their white counterparts. Is there a discernable difference in the quality of services provided to minority and multicultural populations in rural areas? No. The problems that face all rural residents are just magnified for minority and multicultural populations. However, one area that is more of a challenge in rural areas is availability of appropriate interpreters for non-English speaking patients.
“In 1988, NRHA launched the Rural Minority Health Advisory Committee, which encourages national rural- and minority-responsive associations to work to improve health care services and access to rural minority and multicultural populations. On May 13, 2003, we held our 9th Annual Rural Minority and Multicultural Health Conference in Salt Lake City . This conference brought together rural health care providers; private sector organizations; federal, state, tribal and local government employees; allied health professionals and anyone else concerned with improving the quality of health care for rural racial and ethnic minority and multicultural populations. Session topics included health disparities between the general populations and rural minority and multicultural populations; HIV/AIDS; disaster planning; community preparedness, bioterrorism, and emerging populations.
“In addition, if you click on the ‘Minority Affairs’ link on our Web site, you will also find a list of print and Web resources that we have created to help medical personnel improve the quality of care to rural minority and multicultural populations.”
What are some of the advantages and disadvantages for allied health professionals who chose to work in a rural community?
“Rural communities are a different way of life. People who chose to live and work in rural areas are generally more socially self-sufficient. They rely upon friends and family and small social gatherings for entertainment more so than the cultural amenities one may find in the urban areas such as the symphony, ballet or opera.
“Allied health professionals can expect more autonomy and the opportunity to fully practice their professional skills. There is less competition from physicians and other health care professionals and these other health care professionals rely upon the allied health professionals in order to extend their services to more patients. Many rural communities rely exclusively upon allied health professionals for their routine care with backup from other providers such as physicians. Also, the care you give is often much more personal, and rural people tend to be very appreciative of the care they receive. Therefore, professional satisfaction may be greater.”
What’s the future of NHRA? Where do you think the association will be ten years from now?
“I envision NRHA having three to four times the current membership and having a lot more rural consumers as members. We just published our first quarterly magazine that will highlight people and rural communities that are making a difference in health care in their respective communities. Many of these will be allied health professionals. The stories are beginning to pour in and they are very heartwarming. There are many good things going on in rural America and we want people to know. Rural communities tend to be very creative and collaborative in coming together to solve problems or to improve their communities. We hope to tell the world about these unsung heroes.
“NRHA is currently highly respected in the government and Congress for our knowledge of rural health, the expertise of our members and for our educational efforts. As NRHA continues to grow we will become an even greater force politically and in advocacy and education. We are determined to eliminate the health disparities between urban and rural residents, and will work tirelessly to assure ‘quality, access and equity’ for all of rural America .”
Nursing is a profession that can truly move with the person, wherever they choose to put down roots. The job prospects are solid for nurses with employers seeking minority nurses everywhere from small towns to urban centers. Because there is so much opportunity, deciding which nursing specialty and geographical area to live and work can take some soul searching.
While many older nurses are still hanging on to their positions and postponing retirement due to the economy, the job prospects for nurses in the future holds promise.
“There’s certainly evidence to show that currently hospitals and other facilities are not hiring at the pace that they were, simply because people are not retiring or leaving their employment the way that they were, and that has to do with the economy,” says Katie Brewer, a policy analyst for the American Nurses Association in Silver Spring, Maryland, discussing the region in and around the Washington, D.C., area. “It’s hard to trend and analyze data; but from hiring employment data, anecdotally we know that there has been a general slowdown in hiring.”
The nursing job market may be less robust in recent years due to the recession, but Brewer is optimistic about the near future of nursing jobs. “That [slowdown] will change in the next few years as people reach retirement age. They may have been close, but when the economy tanked, they weren’t close enough in order to justify retiring. But in the next few years as the economy recovers and people’s financial situations begin to improve, we’ll see a bottom fall-out in terms of the amount of people that retire and the amount of people that can afford to go to part-time work or leave their job. So there will be another influx of needs in the nursing field.”
One area in particular that Brewer says is on the cusp of major growth is geriatric nursing.
“There’s definitely evidence that there’s a great need in geriatric nursing. We’re on the cusp of almost a 20 million person increase in the age population of 65 and older,” Brewer says. “We’re going to have a tremendous need for nurses that can take care of older adults as well as some of the conditions that those people generally have, such as osteoarthritis, diabetes, heart conditions, and cognitive impairment. So that’s where the biggest growth in specialty needs will be. There’s no question of that. It’s definitely a nationwide need.”
“Because a lot of nursing students are trying to specialize now, it has really placed a void for nurses at the bedside,” says Linda Faye Hughlett, R.N., M.S.N., C.N.M., a certified nurse midwife for the Vanderbilt Nurse Midwives Practice in Nashville, Tennessee. “I see a great need for new nurses [at the bedside] because a lot of new nurses are coming out of school, inexperienced, and not wanting to deal with the challenges that many face on a medical-surgical unit. Also, the appeal of making more money as an advanced practice nurse (APN) is adding to this void. So they have no plan or desire to stay at the bedside and do that kind of grunt work.”
Hector M. Benitez, R.N., B.S.N., M.S.H.A., Care Management Operations Integration Director at WellPoint, in Lebanon, Tennessee, agrees. “I think that minority nurses are really needed at the bedside in medical-surgical situations where they’re on the floor,” he says. “It’s imperative that we have nurses at that level, particularly because that’s when patients are the most vulnerable. They’re lost and confused—especially if they don’t know the language.”
Medical-surgical nursing is an area where minorities, especially those with language skills, can make a huge impact on patient care.
“I’ve seen situations where the nurse comes in to assist a patient and they cannot communicate because of the language barrier,” Benitez says. “The nurse will explain what they’re doing and I always find it kind of comical because if you don’t understand what they’re saying to you most patients just smile and nod their head ‘yes.’ That gives the indication that it’s okay, although they have no clue of what was just said to them, and then the nurse proceeds to do whatever it is they need to do.”
For Felecia B. Green, R.N.C., B.S.N., O.B., nurse manager in the high-risk O.B. unit at Texas Health Presbyterian Hospital in Dallas, Texas, a specialty that comes to mind with significant growth is the nursing informatics field. “The era of a paperless health care delivery system lends itself to a greater demand for nurses to be proficient and versatile in computer technology. Minority nurses are needed in this arena to help navigate and influence the changes that are occurring in health care documentation.”
Finally, Brewer predicts that there will be a need for advanced practice registered nurses in the field as the health care landscape continues to change. “These are nurses that have advanced practice education training and can do things like prescribe medication, prescribe home care, and provide more independent medical and health care services to patients,” Brewer says. “And as more people are getting into the health care system with the affordable care act being fully realized, there’s going to be a huge need for providers in that sense. So advanced practice registered nurses can meet that need.”
As more patients enter the health care system because of widening access to care, the increase in minority patients will require good culturally competent care. And minority nurses are needed across all specialties to meet those growing needs. “It is beneficial to the patients and their families to witness minority nurses thriving in areas that were historically all white,” Green says. “Minority nurses can be advocates to assist in the cultural differences—whether beliefs or rituals—that many ethnic individuals may have. Minority nurses are a window into the future for the younger patients, and may influence perceptions that this career is within their grasp.”
Nurses aim to deliver the best patient care no matter the city or town they practice in—whether it’s a rural hospital or a thriving metropolis. But there are regional differences when it comes to job opportunities, average salaries, and the quality of living.
Quiz: Rural vs. Urban—Which area is right for you? Have you ever thought of working as a nurse in a rural area of the country? Perhaps you grew up in a rural town and want to give back. Or, would the fast-paced environment of a downtown hospital be a better fit for your career and personal goals? Take this quiz to see which area may be the best fit for you. 1. I feel that I can do my best work in ______. A: Facilities where I can take my time with each patient B: Facilities where I get to care for many patients at the same time 2. I would be willing to live in a sparsely populated area if there were incentives such as student loan repayment. A: True B: False 3. I enjoy taking a strong leadership role in my patients’ care where I have more authority to act as a primary care nurse. A: True B: False 4. Which do you value more: A: Lower cost of living B: Cultural diversity Answer Key: Mostly A’s–Small Town USA If you answered mostly A’s, you’re likely open to a nursing career in a rural setting. Visit the National Rural Health Association’s website at www.ruralhealthweb.org for more information. Mostly B’s–Faster-Paced City If you answered mostly B’s, urban cities or larger suburban areas are likely a better fit for your ideal quality of life. Be prepared for a tighter job market, as there will be more competition in larger communities.
Benitez and Alan Morgan, chief executive officer of the National Rural Health Association based in Washington, D.C., both agree that the Southeast region of the country needs more nurses.
“In my experience, there’s a lot of opportunity in the South. But for some reason, I’ve seen nurses who’ve completed school here and the first thing they do is move away,” Benitez says. “But looking around, our salaries have always been fairly competitive with other regions. It’s also been my experience that the cost of living is a bit easier to manage with a nursing salary [in the South] as opposed to moving somewhere in California or up North where your living expenses are going to be really expensive, in relationship to your salary.”
Morgan adds that Southeastern states, such as Mississippi, Louisiana, Alabama, and Tennessee are experiencing nursing workforce shortages. “The Southeast would be where we’re seeing the major need for additional health care and practitioners to be,” Morgan says.
Rosario Medina-Shepherd, Ph.D., A.R.N.P., B.C.R.N., assistant professor of nursing at the Christine E. Lynn College of Nursing at Florida Atlantic University in Boca Raton, Florida, and Vice President of the National Association of Hispanic Nurses agrees that minority nurses are needed in the South. She adds that “minority nurses are presently needed in the higher populated minority areas, including New York, Florida, and states in the West. This is rapidly changing to include areas such as North Carolina that were once not thought to be affected.”
No matter which area of the country you choose to work in, Brewer advises nurses to look for health care organizations that have obtained magnet status.
“Hospitals and other facilities that have magnet designation are definitely the places where nurses want to work because those are the places that are committed to nursing leadership and nursing excellence. And so when people are looking around for jobs, one of the first things that they should ask their potential employer is if they have magnet status or if they are working to become a magnet facility,” Brewer says.
There are many pros and cons to working in both rural and urban health care settings. Many nurses are drawn to rural areas because of programs that recruit them and offer student loan repayment arrangements. Other nurses prefer the hustle and bustle of the city.
“I started my career in an urban environment and quickly adjusted to the multidisciplinary team approach to patient care,” Green says. “It allowed for readily available resources, ongoing training, and utilization of evidence-based practices.”
On the other hand, rural nurses are often considered primary care givers—often working with a greater degree of independence and without much support from physicians due to shortages.
Rosario Medina-Shepherd, Ph.D., A.R.N.P., B.C.R.N., professor of nursing, Lynn University; Vice President, National Association of Hispanic Nurses
Hughlett suggests nurses considering practicing in a rural area ask questions and understand the work environment and how it differs from a heavily populated setting. “They need to know what resources are available for them. These resources can be a very integral component of their survival as well as job satisfaction,” Hughlett says. “If you are an APN, before you sign a work contract, ask who your consulting physician will be as well as the details surrounding that relationship. APNs in rural areas are often left out there by themselves to care for mass amount of patients without feeling support from the medical community.”
Green says nurses considering practicing in a rural area should also consider a number of factors impacting the move. “Nurses should ask themselves whether they are comfortable, proficient, and confident to practice outside of the safety net of having an entire team available for emergent situations,” Green says. “Are they willing to stabilize, prioritize, and give the appropriate intervention until a higher level of care is available? Do they want total autonomy—from admission to discharge?”
While there may be some unique challenges to working in rural areas, Morgan says job prospects are plentiful.
“The current job market for nurses in rural areas is outstanding,” he says. “That’s great news for rural nursing, not such great news for rural America, typically because there is such a significant workforce shortage now in rural areas.”
Morgan also notes some of the perks to rural nursing. “The two selling points for practicing in rural areas: one would be quality of life,” he says. “Living in a small town—it’s a wonderful place to raise a family, and there’s a tremendous sense of community that you have in small towns across the United States. Another benefit is that you’re working in small organizations—small rural hospitals, full health clinics, and small community health centers. When you’re in a small organization, there is a greater opportunity for leadership positions and for innovation in health care delivery.”
Others, like Trang Nguyen, R.N., B.S.N., a nurse manager at Texas Health Presbyterian Hospital in Dallas, Texas, believe minority nurses are especially needed in urban areas. “I see such a diverse population where I am now and have really developed an appreciation for diversity,” she says. “You learn how to care for different people and really tailor your care for them. As a minority, I find myself taking a step back and making sure that I am tending to culturally sensitive aspects for all patient populations.”
Salary Data for Registered Nurses (RN)
RN hourly rate by state or province Texas: $20.38–$35.60 California: $23.83–$50.51 Florida: $19.58–$33.86 Illinois: $19.60–$35.04 Ohio: $19.29–$31.51 Pennsylvania: $19.95–$35.89 New York: $20.08–$39.65 Source: Payscale.com; United States; updated: September 22, 2011; individuals reporting: 44,836
RN national hourly rate by years of experience Less than one year: $15.93–$29.38 1–4 years: $19.16–$31.79 5–9 years: $21.19–$36.86 10–19 years: $22.47–$39.90 20 years or more $23.03–$43.11 Source: Payscale.com; United States; updated: September 22, 2011; individuals reporting: 44,858
RN hourly rate by skill/specialty Medicine/Surgery: $19.69–$36.16 Acute Care: $19.94–$37.09 Intensive Care Unit (ICU): $20.21–$38.85 Geriatrics: $19.26–$34.08 Pediatrics $18.53–$35.74 Labor & Delivery, Birthing: $19.17–$36.82 Emergency/ER: $18.72–$37.23 Source: Payscale.com; United States; updated: September 22, 2011; individuals reporting: 40,004
RN hourly rate by degree/major subject Bachelor of Science (B.S.N.): $21.09–$40.90 Associate Degree in Nursing: $20.35–$36.77 CPR: $24.39–$30.18 Associate of Science in Nursing (A.A.S.): $21.23–$31.06 Diploma, Nursing: $20.53–$37.50 Master of Science, Nursing (M.S.N.): $22.67–39.25 Source: Payscale.com; United States; updated: November, 30 2011; individuals reporting: 15,555
New nursing technology has opened endless opportunities for superior care, says Susan R. Stafford, R.N., B.S.N., M.P.A., M.B.A., Associate Chief Nursing Officer of Nursing Informatics at the Cleveland Clinic Stanley Shalom Zielony Institute for Nursing Excellence. The Zielony Institute oversees the practice and education of more than 11,000 nurses in all aspects of the Cleveland Clinic health system, including inpatient, outpatient, rehabilitation, and home care fields. “From recently introduced innovations to those that are on the horizon, enhanced technology gives nurses the ability to integrate so we can focus on delivering quality, safe, world-class care,” Stafford says.
Nurses have always been information managers at the center of a wheel, according to Patricia Abbott, Ph.D., R.N., associate professor and Co-Director of the World Health Organization/Pan American Health Organization Collaborating Center for Nursing Knowledge, Information Management, and Sharing at The Johns Hopkins University Schools of Nursing and Medicine, and chair of the 11th International Congress on Nursing Informatics in 2012. Everybody touches base with the nurse to get the latest information on a patient, says Abbot. “We’ve always had technology in our lives.”
“Our students come in with every piece of technology known to man hooked on their belt. Sometimes it’s like Jeopardy—we’ve got the answer; now what’s the question?” Abbott says. “We’ve got the technology; now show me how to apply it.” Abbott says the younger generation was raised with technology, impacting the way they communicate and conceptualize. “It’s fundamentally changing the way you think and your belief networks,” she says. “What’s happening is a lot of people are starting to look at this and see they have to adapt or leave.”
As U.S. Secretary of Veterans Affairs General Eric Shinseki once said, “If you dislike change, you’re going to dislike irrelevance even more.”
What follows are some of the top trends in nursing technology today, from the macro-level, government-funded changes to the little gadgets you might soon find in your hand.
Nursing informatics is a growing field that supports nursing processes through technology, including telehealth, home health, ambulatory care, long-term care, education/research, acute care, outpatient settings, software development, and work flow redesign.
“Technology has been growing and work has been done for 40 years, but people didn’t know about informatics education and it was not that widely available,” says Bonnie Westra, Ph.D., R.N., F.A.A.N., associate professor and Co-Director of the International Classification of Nursing Practice Research and Development Center for Nursing Minimum Data Set Knowledge Discovery at the University of Minnesota School of Nursing. She says she’s suddenly seeing informatics classes that previously attracted three people grow into classes of 25. “Now programs are crawling out of the woodwork,” says Westra, also co-chair for the Alliance for Nursing Informatics (ANI).
The Healthcare Information and Management Systems Society (HIMSS) 2011 Nursing Informatics Workforce Survey reported that nurse informaticists play a critical role in the implementation of various clinical applications, including clinical/nursing documentation and clinical information systems, computerized practitioner order entry (CPOE), and electronic health records (EHR). The 2011 data also suggests a substantial increase in salary for nurse informaticists, which is up 17% from 2007.
Kathryn H. Bowles, Ph.D., R.N., F.A.A.N., associate professor of nursing at the University of Pennsylvania School of Nursing, says there are a few programs in the United States for nurses holding a master’s or Ph.D. She added the American Medical Informatics Association (AMIA) is doing a lot of work to promote nursing and medical education in nursing informatics, and the Technology Informatics Guiding Educational Reform (TIGER) Initiative is transforming informatics.
The TIGER Initiative aims to identify information/knowledge management best practices and effective technology to help practicing nurses and nursing students make health care safer, effective, efficient, patient-centered, timely, and equitable. “Nurses are out doing 50%–80% of all care in the globe, and many times they are in the field or in the bush,” Abbott says. “As technologies have gotten smaller, powerful, and more mobile, if we combine a huge workforce with more powerful technologies, we are enabling nurses, birth attendants, and midwives to practice better. When you do that, you improve care to an entire community.”
Telehealth promotes lower-cost health care through mobile communication and video. Laptops, tablets, and smartphones offer video conference capabilities that allow face-to-face visits without travel costs and complications, and provide vital signs and medical history for remote diagnosis and monitoring.
“Telehealth provides specialty services on the turn of a dime without the patient being shipped off to another facility,” Westra says. Telestroke robotics is one example, where practitioners use robotic technology to manage stroke victims in remote areas. Telehealth also is being used for psychiatric consults in prisons, a less expensive and equally effective treatment option.
Abbott worked on a National Institutes of Health–funded study involving implementing telehealth services for minority patients suffering from congestive heart failure. The program placed telehealth monitors in patient homes for remote monitoring, allowing patients to Skype with nurses regarding their health concerns. “Some of my patients are geriatric African American folks with heart failure, and they don’t have transportation, and they might be in the only occupied house in an area of burned-out homes,” Abbott says. Telehealth also can be a lifeline for entire communities, scaling up knowledge levels of community health workers in low-resource areas without a formally trained nurse on site.
“We know there are not enough doctors to go around, and also not enough nurses,” Abbott says. “In reality, when you start looking at the large provider groups that exist around the world, you look at ways you can reach and teach. Many of these folks, both nationally and internationally, cannot travel to the bricks and mortar model of a school to get additional training.”
Gartner Inc., a Connecticut-based information technology research and advisory company, says mobile health, or mHealth, is one of the top 10 consumer mobile applications for 2012. According to the 2009 American Academy of Nurse Practitioners (AANP) Membership Survey, 60% of respondents indicated they used a PDA or smartphone in clinical practice. Applications do not require a large, up-front investment and are simple to download. Health diaries, medication reminders, exercise tips, and applications to track food intake, pain levels, and sleeping habits are helping people monitor their own health.
Cell phones facilitating mHealth are proving to be powerful tools in the Latino and African American communities, particularly with illegal aliens afraid to participate in a formal health care system. Abbott says she’s involved in a movement surrounding texting for health, in which nurses reach out to minority populations with health tips and reminders concerning maternal health, HIV/AIDS, and drug addiction. The National Healthy Mothers, Healthy Babies Coalition text4baby’s Hispanic Outreach program, for example, supports mothers by providing 140 characters of health information and resources to a pregnant woman’s cell phone.
“They don’t have home phones—a lot don’t even have a home—but they have a cell phone,” Abbott says. “We are getting messages to them about appointments and medication refills. We let them text in questions or problems they have because they won’t come to the clinic. It’s a way to reach people through something so many people have these days.”
Over the past two years, the University of San Diego’s Hahn School of Nursing and Health Science has required an iPod Touch for incoming RN pre-licensure students. Instead of carrying multiple books to clinical sites, the iTouch provides clinical reference tools and pharmacology manuals with the tap of a finger.
“They find that having those clinical reference tools available to them very quickly while seeing patients is easier than having to look something up in a book,” says Karen Macauley, D.N.P., F.N.P.-B.C., Director of the Simulation and Standardized Patient Nursing Laboratory and clinical associate professor. The school developed an nTrack application for the iTouch with Skyscape Medical to help students document clinical experiences in hospital sites. Once they graduate, students can compile the data into an e-portfolio for potential employers.
“We decided to require it because it forces students to really embrace technology,” Macauley says. “Once they get into the hospital sites, you’re really looking at the best evidence-based practice and how to apply it to their clinical practice. Without having something at their fingertips to look at right away, they are at a loss.”
Another mobile tool growing in popularity is the electronic tablet. “The whole iPad application, how it will affect patient teaching and patient interaction, will be huge,” Westra says.
Abbott says mobile technology is especially important for nurses, who are incredibly mobile themselves. “We are running from bed to bed to bed, from unit to unit to unit, from clinic to clinic to clinic, from house to house to house,” Abbott says. “Records never seem to go with us, which has caused a lot of errors, redundancy, and wasted effort. Now when you put mobile technology in a nurse’s hand or in her pocket, it allows her to do her job, help her patient, right at the patient’s side instead of running back to the nurses’ station and grabbing a chart or looking on a computer.”
Mobile technology can also be a lifeline for remote nurses in “frontier environments” with less than seven people per square mile, Abbott says. A mini clinic with connectivity enables nurses to provide more services, find the help they need when they need it, and quickly connect through Skype with a specialist to find an answer.
Electronic health records
The federal government set aside $27 billion for an incentive program, as part of the 2009 Health Information Technology for Economic and Clinical Health (HITECH) Act, to encourage hospitals and providers to adopt electronic health records systems (EHR). Policymakers continue to work toward establishing a Nationwide Healthcare Information Network to standardize EHRs, which would provide a seamless exchange of data among physicians, hospitals, laboratories, pharmacies, and other health care organizations.
At the Cleveland Clinic, electronic documentation includes computerized provider order entry (CPOE), nursing care documentation, medication dispensing and administration, and results reporting. The technology improves access to patient information at the point of care and enhances the ability to benchmark, monitor, audit, and report quality measures while offering quality data to support nursing-led research.
The Cleveland Clinic has been implementing EHR technology in stages over the past six years. The most recent implementation was the ICU nursing documentation with device integration. With this implementation, vital signs go directly from the cardiac monitor at the bedside into the EHR.
At the University of Pennsylvania, Bowles’ is examining decision making supported by information technology to improve care for older adults. Her ongoing study, funded by the National Institute of Nursing Research, focuses on the development of decision support for hospital discharge referral decisions. Using an electronic record, patients are asked a series of questions, ranging from their ability to walk to whether they have a caregiver available at home. Through statistical analysis of the answers and information already contained in the EHR, clinicians can make an informed decision regarding a patient’s needs. “Decision support, in general, is a new phenomenon,” Bowles says. “As we start using electronic records, more and more patient data will be available electronically and more developed to remind clinicians of the right thing to do.”
In May 2010, the Office of the National Coordinator for Health Information Technology (ONC) estimated an additional 50,000 health information technology workers will be needed over the next five years to satisfy meaningful use criteria. Abbott is the principal investigator on a HITECH grant to create a six-month, non-degree program for the unemployed to be qualified to build, upgrade, and maintain the implementation of health information technology programs, including EHR systems, at hospitals and clinics.
Centralized monitoring of intensive care units in remote areas is the health care delivery of the future. FHN Memorial Hospital in Freeport, Illinois, is collaborating with the University of Wisconsin e-Care team of intensivist physicians and critical care nurses in Madison, Wisconsin, on eICU care. Small microphones and cameras in each ICU patient room provide a constant link to the e-Care team at UW Hospital. Patient vital information, including heart rate, blood pressure, medications, and test results, are monitored in the FHN ICU and shared in real time with the e-Care team.
If a patient’s condition suddenly changes, the FHN physician and nurses can touch a button and activate a two-way visual and audio link for an immediate consultation with e-Care specialists.
The Mayo Clinic health guide used to be the go-to guide at everyone’s bedside. But the introduction of social media has both patients and caregivers logging onto sites like WebMD and Patients Like Me for health information, advice, and forums to share experiences.
A 2008 Edelman Health Engagement Barometer found the Internet has become the “new second opinion.” Patients with a diagnosis are barely out of the exam room door before typing status updates on their smartphones and searching for support groups via social media.
Many nurses have taken to Facebook and Twitter to promote accurate medical information to help the general population make healthy lifestyle choices, as well as to promote their profession.
Virtual reality simulations
Imagine being in the operating room and making a devastating decision that risks the life of a patient. Now imagine being given a do-over and figuring out the best way to proceed.
Such is the scenario in Second Life, a 3D virtual world becoming popular in nursing education. Westra says universities are buying islands and creating communities in which students develop avatars and run through different scenarios to see the consequences of their decisions. She’s even seen a virtual theater set up where students in their avatar personas can “attend” an author interview on a virtual theater stage. “It’s a chance to have people practice skills and make decisions and study consequences and not kill patients,” Westra says.
Radio frequency identification
Radio frequency identification (RFID) has been traditionally used for tagging equipment, but it’s starting to replace bar coding for patient identification. Westra says she is seeing RFID in nurseries to prevent kidnappings and tagging breast milk to ensure it goes to the right baby. Alzheimer’s units are using it as well to monitor patients prone to wandering.
Experimentally, it also is showing up in operating room equipment. A wand with an RFID reader is replacing X-rays to pick up any sponges or instruments left in patients before they are sewn up. Another experimental use is with intubating patients to check placement rather than using X-ray.
Judy Murphy, R.N., F.A.C.M.I., F.H.I.M.S.S., Vice President of Information Technology for Aurora Health Care in Wisconsin and co-chair of ANI, says RFID is a lot like Global Positioning System (GPS), but added there isn’t a lot of penetration of the technology at this point due to the expense. But it may be something more institutions turn to down the road.
Almost every IV these days is connected to a smart pump integrated with a computer that handles drug infusion calculating. Computerized infusion pumps with dose error reduction systems were developed to alert nurses if a programmed fusion dosage exceeds the hospital’s best practice guidelines.
Some organizations are integrating the pumps with EHRs, allowing physicians to enter information electronically and pass it along via computer to the pump, Murphy says.
Cleveland Clinic is rolling out new IV digital smart pumps designed specifically for high-volume medication infusions. This imitation will be completed and fully implemented in 2012. The Clinic will also be using new smart syringe pumps and smart pain pumps.
Wireless voice-over-IP phones
Through wireless voice-over-IP phones—voice carried over Internet protocol networks—nurses can be more easily reached when they are caring for patients in various rooms throughout a unit. This technology eliminates the need for unit secretaries to make announcements over a loudspeaker. The phone, according to the Cleveland Clinic, helps with noise control, improves efficiency in communication between staff and patients, and streamlines processes.
Electronic patient tracking boards
Similar to wireless voice-over-IP phones, electronic patient tracking boards facilitate ease of communication and coordination of patient care with a quick status display of current activity on a unit. A combination of wireless communication, barcode, and Internet technology, electronic patient tracking boards are replacing white boards in many settings.
Cleveland Clinic first used patient tracking systems in the emergency department and operating room areas. In 2010 the hospital system rolled out a new patient tracking board system to all of the main campus inpatient units.
Electronic patient tracking boards, according to Stafford, decrease the need for phone calls or meetings to find information about patients as they are coming and going. The systems give nursing units a one-stop shop for critical information on patients. A nurse, for example, can easily see if patients are at risk of falling or need extra precautions in isolation.
Point-of-care technology offers access to patient records, labs, medication information, and even second opinions, all from the patient’s bedside. A wireless network and computer allow nurses to access and receive a wide array of information without leaving the patient’s side.
Wireless point-of-care glucometers, for example, submit blood glucose results to the electronic medical record as soon as the clinician checks a patient’s blood sugar level. This technology offers completed reporting and documentation immediately upon the docking of the wireless device into its cradle. The information transaction can also be sent into the electronic medical record.
Workstations on wheels are also used for bedside and point-of-care documentation and information retrieval. Cleveland Clinic has one workstation on wheels for each caregiver working a shift on a nursing unit, providing instant access to a patient’s medical records at the bedside. The Cleveland Clinic finds the system helps nurses confirm all patient information is accurate, including medical history and medications, and improves patient safety for medication administration.
Cleveland Clinic is also rolling out a new Web-based self-scheduling platform for all caregivers. The system offers nursing caregivers convenience and flexibility through the ability to select shifts based on competencies. Nurse managers can now spend less time filling shifts and making phone calls. This technology is relatively new and still uncommon among most health systems, but it is a growing trend and anticipated to be coming to more health systems over the next few years.
“We look at the opportunities that are possible because of technological advancements,” Stafford says. “The common thread is that many of these advancements were developed to help nurses give the patient a positive experience. An enhanced patient experience is very valuable, creating a healing environment that contributes to overall positive patient outcomes.”
While all of this technology is meant to create efficiencies, improve outcomes, and ease the workload, Macauley says it all comes down to how medical professionals communicate with each other. The future of medical technology lies within professionals and students who will embrace it and create a system that lowers health care costs by reducing redundancy.
“Those people who leave the program in technology are thinking out of the box on using mobile devices and mobile technology and looking at ways of being innovative in using technology we’re all exposed to,” Macauley says.