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Frontier Nursing in the Literature

It is the premise of this literature review that frontier nursing is a specialty practice, one that is on the extreme end of an urban–rural continuum, one that is not well known. The notion of frontier nursing as a specialty practice is supported by Jane Ellis Scharff (2010), who stated:

If rural nursing is distinctive, frontier nursing must be even more so. Many of the studies and descriptive articles included in this chapter did not articulate the term frontier; however, the distinction of frontier nursing reveals itself. Until recently, the term frontier was rarely utilized; frontier research and rural research were simply categorized as rural. To complicate matters further, there have also been definitional inconsistencies of the term rural (Bigbee & Lind, 2007). Therefore, as most of the information on frontier nursing is embedded in rural nursing literature, the articles presented in this chapter were ferreted out of searches using the keywords “frontier” and “rural.”

A literature search serves to identify key concepts regarding a particular phenomenon. A concept can be defined as a complex mental formulation of experience (Chinn & Kramer, 1999, p. 61). Since experience can be collective or individual, concepts can be both public and private. For example, the concept of health has both public and private meanings. From a public standpoint, health may be defined as the absence of disease; however, from a private standpoint, it may mean the ability to keep working and providing for one’s family. For concepts to be the building blocks of nursing models, they must have public, or professional, meanings (Walker & Avant, 2005, p. 26). This chapter explicates the public concepts related to frontier nurse practitioner (NP) practice.

The studies included in this chapter represent sentinel research that has implications for frontier NP practice. This includes quantifiable information regarding clinical skills and procedures (CSP) utilized in rural and frontier practice, as well as issues surrounding recruitment and retention of frontier NPs. Additionally, studies regarding the transition of urban nurses to rural settings and NPs to frontier practice add rich narrative insight into workforce challenges in rural and frontier areas.

This chapter also includes articles that describe various aspects of frontier NP practice. Stories of NP practice, particularly those told by the NPs themselves, represent significant descriptive evidence regarding frontier NP practice. This anecdotal evidence highlights key concepts related to frontier NP practice.

The information in this chapter is categorically presented in accordance with the major themes found in the literature. Some themes are grouped together, as the concepts and thematic exemplars are interrelated. In addition, as most individual articles include more than one theme, articles may be cited under one or more thematic categories. Many of the concepts identified in the literature support, and were supported by, the theory of rural nursing. Therefore, this chapter begins with a review of this theory.

  THEORY OF RURAL NURSING

In 1989, Kathleen Ann Long and Clarann Weinert published results from their ethnographic study of rural residents in Montana (Long & Weinert, 1989). The study was based on the assumption that health care needs are different in rural areas than in urban areas. The researchers also made the assumption that all rural areas are viewed as having some common health needs. In addition, the assumption was made that urban models were not appropriate to, or adequate for, meeting the health care needs in rural areas (Winters & Lee, 2010).

The researchers interviewed rural nurses in Montana and identified concepts such as insider–outsider, role diffusion, and lack of anonymity as characteristics of rural nursing practice. Long and Weinert suggested that acceptance as a health care professional is often tied to personal acceptance by the community. Results of their study indicate that community involvement is utilized as a method to overcome this barrier (which may add to the social capital of remote communities).

In addition, they also sampled rural residents in Montana regarding their health beliefs and practices. Although their study participants represented a relatively narrow sample of rural dwellers and nurses, their sentinel research continues to contribute to nursing science and represents the only widely accepted mid-range theory for rural nursing practice (Colledge, 2000; Guadron, 2008; Lauder, Reel, Farmer, & Griggs, 2006; Senn, 2013; Sharp, 2010). Other researchers have replicated Long and Weinert’s findings and have identified additional concepts. These concepts are related to role stress and being on call as well as issues with confidentiality in small towns (Schmidt, Brandt, & Norris, 1995).

Based on their findings, Long and Weinert developed relational statements regarding health care characteristics of rural residents (Winters & Lee, 2010, p. 10). These statements can be summarized as follows:

       1.   Rural residents define health primarily as the ability to work or be productive.

       2.   Rural residents are self-reliant and resist accepting help or services from outsiders.

       3.   Health care providers in rural areas must deal with a lack of anonymity and much greater role diffusion than providers in urban or suburban settings. In addition, they also reported a greater sense of isolation from professional peers.

In an effort to replicate a portion of Long and Weinert’s study and to increase the understanding of frontier residents’ perceptions of access to health care, a qualitative study was conducted in a frontier town in southern Montana (Smith, 2008). The specific aims of the study were: (a) to explore frontier residents’ health care access to resources; (b) to investigate frontier residents’ utilization of health care services; (c) to ascertain reasons frontier residents seek health care; and (d) to explore the residents’ overall satisfaction regarding their health care options. Smith interviewed 11 participants who lived in the same frontier town. Ten of the participants described themselves as being healthy; four of these participants further stated that their lifestyle (frontier living and ranching) kept them physically active and led to their feelings of being healthy. All residents interviewed felt they had some form of access to health care resources, even if this meant driving 70 miles to the nearest provider. One participant stated, “You know, we’re used to distance, we live with it, it’s just a known factor” (p. 44). Three of the participants mentioned informal health care resources, such as soliciting health care advice from a former nurse who worked as an emergency medical technician on the volunteer ambulance or trying to take care of their own ailments using folk remedies. One elder resident stated, “essential oils, things like peppermint; you know if you get a stomach ache. It’s like the cold, it’s the flu, you know, it’s a virus. You’re going to get over it. You don’t do antibiotics unless you have to” (p. 46). Several participants mentioned the need for local emergency services because “we’re so darn far from help” (p. 40). Four of the participants felt an NP would be a benefit to the community, but wondered if there would be enough patients to maintain a practice.

All participants had seen some type of health care provider in the recent past; average length of time from last visit was 1 year. The cost of care was frequently cited as a negative component of accessing care. Patient satisfaction with their health care providers was high even though they traveled many miles to see them and sought care infrequently.

Smith’s study provided new insight into the health care perceptions of a small number of frontier residents in a very limited geographic area. Despite this limitation, it validated some of the concepts identified in rural nursing theory, such as placing a high priority on work, self-reliance, and the use of informal health care resources.

  FRONTIER SKILLSET

A recent study documented the type and number of psychomotor CSP utilized by NPs in the rural state of Oregon (Lausten, 2013). A survey instrument was developed, which included 90 CSP. Among other items, respondents were asked how often each procedure was performed and if they had received training on those procedures during their NP preparation. The survey found significant dichotomies between urban and rural practice. Rural NPs reported the use of a greater number of CSP; furthermore, a majority reported learning most of the CSP outside of their NP educational programs.

In all, 23 of the CSP on the survey were rated by 50% or more of the respondents to be either very important or important to their practice. Results of this survey suggest that NPs planning to practice in rural or frontier areas may need broader exposure to and training in CSP. While the author listed the practice settings (urban, n = 200; suburban, n = 102; rural, n = 133; frontier, n = 3) in the respondent demographics, the percentage or number of times the CSP were utilized according to those practice designations was not reported.

In a descriptive article, Mary Ellen Connor (2002) drew upon her varied 20-year career as an NP to provide insight about the skills and personality traits beneficial for providing rural primary care. This insight came as a result of her transitions from frontier to rural to urban practice. Foremost is the possession of a sufficient amount of urgent care experience to handle a wide variety of patient problems. Knowledge of referral specialists is very helpful, particularly when urgent telephone consultations are needed. Delegation skills and familiarity with the scope of practice of those people with whom the NP interfaces are also important. Competence in basic laboratory skills, such as vaginal wet mounts, urinalysis, hematocrit and hemoglobin, rapid Strep screens, urine pregnancy testing, and stool testing for white blood cells, is necessary. Cardiopulmonary resuscitation skills and advanced cardiac life support for both children and adults are vital and must be kept up to date. Good x-ray interpretation skills and familiarity with the radiology group that formally reads films are needed. The NP should know where lab tests are referred and when to expect the results. Lastly, Connor noted that access to Internet resources can be the best way to keep current on research findings and medication updates.

  EXPERT GENERALIST

The frontier NP has been described as an expert generalist, a provider who has training in all aspects of care for all age groups (Rozier, 2000). Roberts, Battaglia, Smithpeter, and Epstein (1999) support this concept and also note that rural and frontier providers often function alone, with few resources and little support. This concept, one of an expert generalist rural NP, revealed itself early in the history of the profession.

Loretta Ford, RN, and Henry Silver, MD, started the first practitioner program at the University of Colorado in 1965 (Edmunds, 2000). Less than 10 years later, Lynne Vigesaa found herself working in the newly developed NP role at a rural clinic in Washington state (Vigesaa, 1974). Vigesaa was a school nurse who moved to a rural area to receive on-the-job training as an NP at a small community clinic. She completed an intense 9-week training program before she and a fellow trainee opened the Darrington Nurse Clinic on April 10, 1972.

The new NPs met with their physician-mentor periodically for review of difficult problems. Their mentor was also available for phone consultation. It was necessary to collaborate with a physician as the NPs found their position with regard to prescription medicines and procedures (suturing, joint injections, and incision and drainage) somewhat tenuous under Washington’s new nurse practice act. Vigesaa states that the NPs did everything from attending the delivery of a premature infant to digitalizing an 84-year-old woman. The clinic had regular hours; however, Vigesaa describes her practice as a 24-hour job. The nurses’ commitment to providing holistic care to their community is evident in the article. They started parenting classes, a free venereal disease screening clinic, a sex education program, first-aid classes, and group discussions on nutrition, dental care, and alcoholism.

Another example of the expert-generalist concept is provided by Burnett (1999), an NP in rural Idaho, who saw patients of all ages. Children were most commonly seen for upper respiratory complaints or general injuries, with teenagers and middle-aged adults being seen most often for routine physical exams. Elders were often seen for medication management. Burnett cited the organizational skills, solid background in patient assessment, and decision-making abilities developed in the registered nurse role as of paramount importance for preparation of the rural NP. The ability to multitask is also important: she described a scene where she was interrupted while in the middle of an incision and drainage procedure to evaluate, stabilize, and prepare for transfer of a man who walked into the clinic with chest pain.

In rural Idaho, Marie Osborne (Hardesty, 1995) also noted the expert-generalist nature of her practice. She described her practice as diverse: (a) the usual colds, earaches, and pneumonias; (b) the poison ivy and fishhook injuries in the summer; (c) skiing and snowmobiling accidents in the winter; and (d) automobile accidents and falls year-round. She also found it helpful to be comfortable with dermatological conditions, as she saw a number of skin problems in her practice.

Leslie Rozier (2000) also provides a description that illustrates both the expert-generalist characteristic and the multitasking skills required of the rural NP. Rozier describes a situation in which the NP, who is infusing intravenous (IV) fluids into a dehydrated 6-month-old, is called upon to obtain radiographs for and treat an 11-year-old with a fracture/dislocation. The child’s family had no insurance, so while monitoring the 6-month-old and the 11-year-old, the NP made phone calls to secure emergency funding to allow the child and his mother to fly to the mainland for surgical care. Just as the NP was accomplishing this task, a resident walked in holding an injured cat, which radiographs confirmed had a fractured pelvis. After giving care instructions for the pet, a call came in: a fisherman had amputated four fingers, and estimated time of arrival to the clinic was 2 hours.

These varied challenges may be the motivation that attracts nurses to rural practice (Mahaffy, 2004). One nurse describes the following scene: The opening ceremony of a new health clinic that community members had struggled to open coincided with both a motor vehicle accident and a bee sting reaction. With competing requirements of stabilizing the trauma victim for ambulance transfer and the need to respond to anaphylactic shock, “we were asking people attending the clinic opening to sit with one patient while we were working on somebody else.” Besides emergency, urgent, well, and chronic illness visits, home visits are a routine part of this practice. One nurse noted that during a community outbreak of strep throat, families were sharing personal items and dishes; she educated them and gave each a personal water bottle.

  TRANSITIONS

Kathryn Rosenthal chose a narrative design to provide rich text for an interpretive phenomenological research study on nursing transitions. The purpose of Rosenthal’s (1996) study was to explicate how urban nurses become rural nurses, and through her research provide an educational model to prepare nurse generalists to excel in the rural setting. The specific research aim was to describe the lived experience of rural nurses through their stories. The researcher asked eight generalist nurses who worked in a rural acute care hospital (less than 25 beds located in a mountain setting) to tell the story of how they adapted and excelled in a rural setting after practicing in an urban setting. The author found that four themes emerged from the data:

       1.   Going With the Flow: Fluid Role

       2.   Fish Out of Water: Expert to Novice

       3.   Still Waters Run Deep: Self-Reliance

       4.   Life in a Fish Bowl: Contextual Knowledge of Patients

The first theme contained subthemes related to role diffusion, a concept noted in rural nursing theory. These subthemes involved the amount of flexibility required by a rural nurse, the lack of ancillary support, and the shifting priorities that faced nurses on a daily basis. The subtheme, fluid role, speaks to the diversity of rural practice and the broad generalist scope of the role in which the rural nurse is expected to function. One participant even relayed a story of helping to x-ray a horse (Rosenthal, 1996).

The second theme contained subthemes related to dualism within the nurse’s knowledge base. The participant may have been a surgical nurse, an intensive care unit (ICU) nurse, or a hospice nurse working at an expert level in the urban setting, but now in the rural setting she becomes a novice when working out of her comfort zone as a rural generalist must do. Nurses may be called from the delivery room to the emergency room within the same shift or even within the same hour. The researcher states that when urban nurses come to the rural nursing setting feeling confident of their previous knowledge base, their confidence is challenged almost immediately due to the breadth of knowledge needed in the rural setting.

The third theme emerged from subthemes related to the rural nurse’s ability to thrive on variety and the ability to stay calm in the middle of chaotic situations. The subtheme self-reliance represents the rural nurses’ realization that you are alone in situations, where beforehand, you would have had another professional’s guidance or support.

The final theme, life in a fish bowl, illustrates the unique position of the rural nurse where the majority of the patients she cares for will be personally connected to herself, her family, or her friends. Subthemes were identified as: caring for a known person, the discomfort of caring for a friend, the positive aspects of knowing the patient, and how knowing the patient touches your heart and soul. This theme highlights the distinct possibility that the rural nurse may need to care for her own husband, child, mother, or brother in an emergency situation.

Rosenthal’s study reinforces concepts that have been previously identified; however, it does so with rich, contextual data that allow the reader to become absorbed in the story and wonder how they would respond in similar situations. This function of narrative storytelling is similar to the concept of rehearsing for practice that Benner, Sutphen, Leonard, and Day (2010) describes to promote the use of case studies in the classroom.

Whereas Rosenthal studied the transition of registered nurses to a rural setting, Anna Lythgoe (1999) conducted a phenomenological study of the transition of NPs to practice in a frontier setting. Lythgoe interviewed six NPs providing primary care in frontier settings (operational definition was counties with less than seven persons per square mile), in an undisclosed state in the United States. The purpose of Lythgoe’s inquiry was to explore the transition of frontier NPs from prepractice expectations to current practice realities. Participant criteria included at least 3 years of practice as an advanced practice nurse and current practice in a frontier setting. The sample consisted of six family NPs, five female and one male. Four of the six were master’s prepared, one had completed a diploma program, and one was a baccalaureate program graduate. Their ages ranged from 39 to 65 years, with five stating they had moved to the frontier area for personal and family reasons.

Lythgoe’s (1999) interview guide consisted of four main questions: (a) How do perceptions of the advanced practice role held by NPs in the frontier setting vary from their individual perceptions while aspiring to their current role? (b) What are the successes and the failures that have helped to shape NPs’ current perceptions and practices? (c) How adequately do NPs believe they were prepared educationally and experientially to provide primary care in the frontier setting? and (d) How would NPs providing primary care in the frontier setting address the limitations they have experienced if given the opportunity to adjust the preparatory phase of practice? Reporting all responses is beyond the scope of this literature review; however, selected responses may provide insight into some of the concepts that emerged from the narratives in this book.

Regarding the issue of dealing with unexpected complexity of patient problems, one respondent stated, “The role is more complex than I thought it would be . . . there is a lot more to know and there is more responsibility than I really anticipated” (p. 40). Lythgoe (1999) noted a strong thread of independence among the respondents exemplified by these statements: “The degree of autonomy and the level of responsibility are higher than I had anticipated” and “it has increased my responsibility but my freedom has been allowed to blossom” (p. 40).

Working with frontier populations may require knowledge of policy considerations and definitions such as medically underserved or health care professional shortage area (Hart, 2012). Regarding policy, one respondent stated, “I think the politics are so burdensome, it makes you question what you are doing . . . everything is very complicated and if I could do what I do in a simple way, I would like it . . . but the politics keep it from being simple” (p. 41). Most of the respondents felt successful if their patients had positive outcomes (Lythgoe, 1999). One respondent felt very successful when patients told him that he had made a positive difference in their lives.

Frontier NPs may practice as solo providers who find the boundaries between nursing and medicine blurred. One respondent thought too much time was spent trying to differentiate the boundaries and spending time trying to set and defend them was a waste of time. The majority of respondents felt their preparation was adequate, but suggestions for improvement were to include more 6-week specialty rotations in NP programs and provide more time to practice clinical skills. From an experiential perspective, most felt critical care and emergency room care were the most advantageous prerequisites. Specifically, one respondent stated, “I think we lack emergency care and trauma care in our education. I think we need to be hit hard in the head with emergency. What’s the worst case scenario here?” (p. 51).

All respondents in Lythgoe’s (1999) study felt successful. They had replaced professional anxiety with knowledge of their resources and how to access answers to their questions. Lythgoe concluded that the successful transition into frontier practice required the development of professional relationships among physicians, other NPs, and other care providers. Four major nursing competencies emerged as Lythgoe analyzed her data: (a) intellectual, (b) technical, (c) interpersonal, and (d) moral.

The strengths of Lythgoe’s (1999) study include the rich narrative data gathered. Lythgoe’s findings have implications for NP programs as well as policy makers. A limitation of her study is that all respondents practiced in the same state. Although this makes the findings less transferable, the descriptive evidence provides valuable emic information regarding frontier NP practice.

  PERSONAL AND PROFESSIONAL CHALLENGES

In an article titled “The Advanced Registered Nurse Practitioner in Rural Practice,” Schmidt et al. (1995) describe factors that make practicing with rural populations unique. These factors include: (a) creatively addressing the common rural problems directly related to health care, such as limited resources and equipment, and (b) establishing a high degree of positive visibility in the community. They also noted that the ease of accessibility of the rural NP creates a feeling of always being on call. The authors also found that a high level of job stress is produced by treating family and friends as patients.

Other researchers suggest that NPs experience significant difficulties as they care for patients whose illnesses may be beyond their training and expertise and whose suffering is severe. They also suggest that cynicism, isolation, and impairment are potential consequences of rural and frontier practice (Roberts et al., 1999).

Rozier (2000) illustrates the concept of always on call in some rural practices. Rozier stated that whenever she took time off to leave the island, where she lived and practiced, the islanders worried about their health and safety; therefore, they would post a lookout to watch for her return. This scenario illustrates the reality of 24-hour call; even though the employment package may call for Monday through Friday, 8 a.m. to 5 p.m., local residents know how to find the only health care provider. Morally and ethically, she could not deny care to her neighbors.

Personal challenges were discussed by other NPs as well and include: (a) long hours, (b) frequent calls, (c) issues with confidentiality, (d) provision of services that may conflict with personal beliefs such as abortion and domestic violence, (e) alternative forms of medical treatment, and (f) maintaining one’s professional skills (Burnett, 1999; Dean, 2012; Rozier, 2000).

Seasonal variations in community population can be both a personal and a professional challenge. A seasonal increase of one or 1,000 people does not bring with it an increase in medical providers, just an increase in the workload of the provider on call. Fluctuations in patient population and urgent care issues were just a few of the issues described by Marie Osborne in an article spotlighting her frontier practice in Stanley, Idaho, resident population 100 (Hardesty, 1995). Osborne was the sole health care provider for a clinic that provided both primary care and emergency care for patients, 7 days a week, 24 hours a day. During the winter months, the population increased to 300 due to winter recreational activities and dramatically increased in the summer due to its close proximity to a national recreation area.

Johnson (1996) also discussed these issues. Her clinic’s volume and patient population varied seasonally. During the summer 50 to 60 patients were seen a day. Many of these were cannery workers who sustained trauma as a result of their high-risk work environment. In addition to trauma care, this NP’s practice included adult primary care, well-child examinations, and prenatal care. She covered the clinic and emergency department every day and was on call every other night, including weekends.

Long work hours are a personal challenge cited by Rozier (2000). In a series of vignettes, she describes challenges particular to her setting. For example, after putting in a 15-hour day, a boating accident victim, a fisherman with a ruptured diaphragm, broken ribs, collapsed lung, and pelvic fractures, was brought to the clinic. It took 18 hours for a storm to quiet long enough to get a helicopter off for the 800-mile journey to the hospital. During the wait, fighting exhaustion, Rozier monitored and stabilized the patient.

The solo NP in a very rural self-managed clinic described challenges that were unique to her setting (Gorek, 2001). Her practice consisted of patients in all age groups. Consistent with other rural and frontier practices, Gorek provided preventative, acute, chronic, and minor emergency care. She also described issues that were unique to her practice setting. These included lack of transportation, lack of specialists, and injured or ill tourists on a seasonal basis. She noted that not having immediate diagnostic services such as labs and x-ray was a challenge in her setting. Mahaffy (2004) also described practice challenges related to the lack of laboratory services. Through community fund-raising efforts, Mahaffy’s clinic had purchased the CoaguChek system for monitoring anticoagulant dosing to therapeutic levels and a hemoglobinometer for monitoring patients with anemia.

Role diffusion is another professional challenge. Evidence of role diffusion, a blurred boundary between the role of an NP and the roles of other health care professionals, is present within the descriptive evidence. Vigesaa (1974) discussed how the geographic isolation and lack of comprehensive health services, such as psychiatry and social work, affected the community: “We sometimes must try to fill in for those who otherwise would receive no services at all” (p. 2027). This statement provides evidence of both the role diffusion rural NPs face and anecdotal evidence that the rural NPs’ practice may overlap into mental health.

The boundary lines of rural NP practice may also cross over into veterinary medicine. In addition to Burnett’s (1999) description of caring for an injured cat, and Rosenthal’s (1996) description of x-raying a horse, Johnson (1996) described herself as a “de facto veterinarian” since the veterinarian only came to their isolated Alaskan bush town every 2 or 3 months. In light of this descriptive evidence, frontier NPs should not be surprised to find themselves caring for pets as well as patients.

  ISOLATION AND EMERGENCY MEDICAL CARE

As noted in the prior section, not every NP may be suited for frontier NP practice. The stories told in this section are from NPs who appear to thrive on it:

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