11

Narrative Knowledge

The concepts related to frontier nurse practitioner (NP) practice noted in the Chapter 3 summary of the literature (Table 3.1) are supported by the participant narratives. Additional concepts and themes emerged from the participant stories. These concepts, and the themes that exemplify them, represent narrative knowledge. This chapter illustrates how this narrative knowledge was utilized to support a conceptual model for frontier NP practice.

  REFLECTED EXPERIENCE AS KNOWLEDGE

Experiences have both an interior and an exterior landscape (Gadow, 1995). The interior landscape represents introspection, when one examines one’s own thoughts or feelings related to an experience; in contrast, the exterior landscape represents the facts related to the experience. Narratives present a holistic view of experience as they combine both landscapes simultaneously. This allows the narrator to simultaneously relate a chronology of events while critically reflecting on those events.

When nurses relate stories of nursing situations, the stories represent reflected experience. The reflected experience is not identical to the experience itself; it occurs only in retrospect when the worth of the meanings, or cognitive ideas, is critically inspected in view of the results of the experience (Dewey, 1969–1991, pp. 27–28). Reflected experience, as knowledge, exists within nursing actions in an implicit and uniquely personal fashion. This occurs because reflected knowledge is derived from experiences that are inherently unique and value laden (Medina & Castillo, 2006). When reflected experience is expressed in story form, the reflected knowledge becomes narrative knowledge.

Narratives allow nurses to communicate nursing praxis. This occurs because narratives reveal the entirety of the nursing situation. Praxis is a term that connotes value-grounded, thoughtful reflection and action that occur in synchrony (Chinn & Kramer, 1999, p. 256). Narratives include not only the events and outcomes, but also the narrator’s feelings and the thought processes utilized during the situation. This is much different than observing a nursing situation; it is enhanced by reflection of the narrator. Narrative knowledge results from this reflection; it is the synchrony of the cognitive, the aesthetic, and the moral knowing (Nairn, 2004). It is through this mechanism that the stories in this book represent narrative knowledge regarding frontier NP practice.

  TYPES OF FRONTIER KNOWLEDGE

Nurses care for patients in a holistic manner. This requires different types of knowledge that synchronize to inform nursing actions. The narrative knowledge illustrated in the participant stories synchronizes several types of knowledge, or ways of knowing.

In 1978, Barbara Carper introduced four patterns, or ways of knowing, nursing knowledge: (a) empirical, (b) esthetics, (c) personal knowledge, and (d) ethics. Peggy Chinn and Maeona Kramer (1999) advanced Carper’s theory by proposing that these knowledge patterns originate from one of four knowledge domains: (a) empirics, or scientific competence; (b) personal, the therapeutic use of self; (c) ethics, the moral/ethical comportment of nursing practice; and (d) aesthetics; transformative nursing art/acts. They further theorized that these knowledge domains do not stand alone; rather, each domain informs and is informed by the others. Sally Gadow (1995, p. 213) contributed to the epistemological discussion by stating that narratives themselves are a way of knowing because through nursing stories we offer one another our experience.

Jill White (1995) proposed a fifth way of knowing: sociopolitical. Sociopolitical knowing addresses the wherein of nursing. It causes nurses to question the taken-for-granted assumptions about practice, the profession, and health policies. Sociopolitical knowing has two components: the sociopolitical context of the persons (nurse and patient), and the sociopolitical context of nursing as a practice profession. The second component includes both society’s understanding of nursing and nursing’s understanding of society and its politics.

The narrative knowledge revealed in the participant stories also follows patterns: (a) knowledge of skills that are distinct to frontier NP practice, (b) knowledge that is unique to the frontier context, (c) the political knowledge to make an impact in frontier health care, and (d) art and ethics that are distinctly frontier oriented. It is the contention of this book that these four types of knowledge are required for effective frontier NP practice, or praxis. The model depicts these types of knowledge as: (a) contextual knowledge, (b) frontier skills and competencies, (c) political knowledge, and (d) art and ethics. These four types of knowledge are discussed in the following sections.

Contextual Knowledge

Frontier NP practice is a specialty practice. Contextual knowledge is knowledge that is required for each type of specialty practice. This includes knowledge related to the concepts outlined in rural nursing theory. When taken to the frontier, these concepts have expanded meanings.

In rural nursing theory, health is primarily defined as the ability to work or be productive. Ann’s narrative, which includes the story about the man who broke his leg but did not come into the clinic until the work was done, exemplifies this concept of rural nursing theory. When taken into the frontier, this definition of health also has systems implications. The notion that rural dwellers don’t stop working until the job is done impacts the availability of volunteer emergency medical services (EMS) in frontier areas. Ann’s narrative provides an example of this concept when she discusses the lack of volunteer EMS personnel during haying or harvesting season.

The notion that rural residents are self-reliant is evident throughout the narratives. In the frontier setting the adage necessity is the mother of invention is applicable. This self-reliance is primarily due to the lack of available resources. Ann’s narrative exemplifies this notion when she discusses using farm gear in lieu of personal protective equipment. An entire community can also be self-reliant. As federal subsidies in frontier areas dwindle, frontier communities have turned inward for solutions to finance health care clinics in these areas. Ann’s narrative is an example of this concept as her community developed its own local tax base to fund their health care needs.

In rural nursing theory, the concept of insider/outsider is related both to the skepticism that rural dwellers have about accepting help or services from outsiders, and to the notion that health care providers who are new to the community are outsiders. Bob describes his first day of frontier NP practice, a day when he went above and beyond the community’s expectations of a health care provider. Bob felt this gave him credibility with the community. This implies that as a newcomer he needed to gain acceptance. This supports Long and Weinert’s statement that some nurses use community involvement to gain acceptance. Community involvement is related to the idea of social capital, which is a concept woven through the narratives.

Skepticism about accepting help or services from outsiders was supported by the narratives as well. Bob states that receiving the 330 grant was both a “godsend and a curse.” Most participants relied on grant funding and federal programs to prop up frontier health care systems; however, they are worried about changes in federal priorities that could dry up these funding sources.

In this book, the concept of outsider also applies to a broader context, the perspective that federal or corporate agencies have regarding health care in the frontier. Outsiders try to “put a round peg in a square hole” when it comes to policies regarding the provision of health care and related services in frontier areas. This concept was exemplified by one of the themes that emerged from Ann’s story: it doesn’t work here.

Role diffusion has been described as the need to function in multiple roles both in one’s personal and professional life (Long & Weinert, 1989). For a rural nurse, this might mean working across several hospital departments in one shift. The examples provided by Long and Weinert were: (a) doing an EKG, (b) drawing labs, (c) delivering babies, or (d) cooking meals if the hospital was snowed in. In the frontier, this concept is extended to include skillsets beyond patient care. Both Bob and Ann discussed the need to act as both the clinic administrator and the clinic provider. Bob exemplified this concept when he discussed the need to build reimbursement systems for his clinic and the need to write grants to maintain services. Lori also exemplified the concept of role diffusion when she talked about shoveling snow on the walkway into the clinic.

The concept of lack of anonymity is widely supported in the narratives. This is exemplified with the concept of reciprocity of care, a theme that emerged from Pam’s narrative. This concept was reinforced by Lori, who stated, “Everyone knows everyone else’s business.” It was also exemplified by Pam, who chuckled at the thought of privacy in a small town and stated that everyone knew whose car was parked in front of the clinic.

The themes frontier culture, a different mindset, a barren health care landscape, it doesn’t work here, and flying solo all support the concept of contextual knowledge related to frontier NP practice. To practice effectively, frontier NPs must have knowledge regarding frontier culture. This includes specific knowledge related to local industries and economies. This may also include knowledge about seasonal practices such as harvesting and haying, which may affect local resources. This is knowledge very similar to that which is required for industrial nursing. Frontier NPs must familiarize themselves with treatment for the common injuries in their geographic setting. This may include injuries related to farm equipment, logging, or mining. In recreational areas, this may extend to knowledge regarding bicycle, motorcycle, snowmobile, or skiing injuries.

To practice effectively in frontier settings, NPs must have a different mindset. NPs must have knowledge of both formal and informal local resources. They must keep in mind that frontier dwellers live in a barren health care landscape and have limited health care resources. Referrals for specialty care or sophisticated diagnostics may have to be reserved for complex or unusual cases. It doesn’t work here means that to practice effectively, frontier NPs need to know what does work in their clinic or their community. It may require adaptation of practices learned either in their NP programs, or from prior work experiences. It may also involve using knowledge and skill to bring new systems—systems that do work in the frontier setting. This implies knowledge of what is needed and how to get it accomplished, such as grant writing or the use of innovative technology.

Skills and Competencies

The concept of the frontier NP as an expert generalist is well documented. The narratives in this book demonstrate the wide range of skills that frontier NPs utilize. The participants managed situations ranging from emergency/trauma care to caring for pets and identifying skeletal remains. This wide skillset also encompasses the care of patients across the life span, from the cradle to the grave.

Flying by the seat of your pants implies being in a situation where either there are no protocols to follow or little is known about the situation. This requires a wide array of clinical skills and knowledge to proceed in an ethical manner. It may also involve writing new protocols, ones that reflect the available resources and referral networks.

Both specialty care and the availability of specialized diagnostic equipment are severely lacking in frontier communities. Gary Lausten’s (2013) study demonstrated that rural NPs utilized a wider variety of procedures than urban NPs. In the frontier, competency involves not only the ability to perform procedures, but the ability to practice in isolated settings with limited resources. Therefore, to accurately diagnose patients’ problems, frontier NPs primarily rely on their history taking and clinical exam skills. This involves both maintaining a current knowledge base and the use of available resources to find answers to patient problems. In situations when a patient must be sent to a larger service area for diagnostics or referrals, the NP may have to act as a distance quarterback to provide patient-centered coordination of care.

To practice effectively in frontier settings, NPs must be capable of flying solo; that is, practicing independently. As solo providers, frontier NPs must be capable of providing comprehensive primary care, including managing emergency/trauma situations and mental health concerns. At times these situations may involve more than one patient. This requires strong organizational skills and the ability to make quick decisions in emergent situations.

The ability to take and read x-rays has been identified as an important frontier skill. This ability enhances both diagnostic and triage capabilities in the frontier. Sending patients to the nearest hospital to have a chest or extremity x-ray might not be a reasonable choice, as some patients lack private transportation. Removing an EMS ambulance from the community for up to 6 hours due to an avoidable emergency department (ED) transport could prove fatal to the next emergency patient.

Mental health resources are severely lacking in frontier communities. Five of the seven participants found this lack of services to be particularly challenging. Ann felt that even one untreated patient caused significant financial hardship for her community. The case she cited also caused extreme stress on the local resources.

In Chapter 2, it was noted that teen suicide is higher in frontier areas. Jim’s narrative illustrates how one frontier NP can make a difference. The narratives illustrate that frontier NPs must be comfortable prescribing medications used to treat common mental health conditions and they must also have a working knowledge of the regional referral system for acute cases. Additionally, NPs use their social capital to promote informal mental health services such as support groups and crisis interventions.

Interdisciplinary practice was evident in the exemplars. Ann stated that she “couldn’t sustain a life” without the emergency medical technicians (EMTs); Lori depended on and worked closely with both the fire department and the sheriff’s department; and Bob, Lori, and Ann had all trained emergency services volunteers. The narratives indicate that these working relationships may have been initiated by the isolation that characterizes frontier communities; however, the narratives also indicate genuine mutual respect between the disciplines. This is illustrated by the exemplars, “we work together for the benefit of the patient,” and “I really respect them for their selfless service.”

Innovation is required in emergency situations and everyday practice. There are several examples of the use of innovation within the narratives. Sue talks about the usefulness of the electronic medical record when consulting with specialty physicians. Pam talks about technology in the emergency room that allowed her to speak with off-site physicians during emergency situations. Ann wrote a thesis about the use of broadband for tele-health, and Bob wrote grants to get updated equipment, such as digital x-ray, for his community.

Political Knowledge

Political knowledge has two aspects: knowledge of policy and the knowledge of what is required to act or advocate for one’s community. It is the knowledge of policy that is necessary for administration of a frontier clinic. There are multiple federal programs that support rural health clinics. Administrative and political knowledge are used reciprocally to help NPs stabilize access to local health care. The participant narratives provide evidence that frontier NPs utilize knowledge regarding funding sources, such as grants and programs that offer enhanced reimbursement rates, to benefit their communities. Although only two of the participants had administrative roles in their clinics, all participants were aware of specialized billing methods and enhanced reimbursement rates for rural services.

The theme shifting sands reflects changes in federal programs and policies regarding frontier health care. Soon after the first NPs graduated, federally subsidized physician extender programs were developed to assess the effectiveness of putting NPs and physician assistants (PAs) in rural areas. Partnering NPs with physician collaborators also provided a mechanism that allowed Medicare for pay for NP services. In 1977, enactment of the Rural Health Clinic Act further bolstered NP practice in rural and frontier areas. These programs were developed to ensure a Medicare safety net for the rural elderly, and to support existing rural and frontier health care systems, such as National Health Service Corps clinics. However, a shift occurred in the early 1990s, starting with the Federally Qualified Health Clinic (FQHC) program and culminating with the Affordable Care Act (ACA). These programs have shifted federal funding from programs that are geographically based to those that are population based, thereby leaving the future of frontier health care undecided. Effective frontier NPs keep abreast of health care policy and how changes impact health care in their communities.

Changes in policy have caused some frontier clinics to merge with larger health care organizations. These changes present both personal and professional challenges to NPs who provide care in these settings. NPs will need to decide when it is best to go with the flow, and work within new programs, and when to swim against the current, to muster both personal and political power to advocate for their communities through policy change.

Nurses advocate for health care equity among groups and ensure that the voices of the disenfranchised are heard. Advocating for the good of others involves leadership skills. It was evident throughout the narratives that the participants demonstrated leadership in their communities.

Art and Ethics

The art and ethics of nursing practice are intrinsically woven. Ethical knowledge guides behavior; it allows nurses to decide the best course of action in certain situations. The art of nursing entails how those ethical decisions are carried out. Both concepts are brought to light within the narratives.

Ethics can be conceived of as a personal/professional concept or more globally in terms of social justice. Woven throughout the narratives are examples of patient-centered, ethical situations. Some of the participants told stories about emergency situations, situations in which they felt out on a limb or in over their heads. These NPs had to make split-second decisions about the ethics of providing care. One might say that certain situations, such as delivering a double footling breech in a remote area, were beyond the scope and comfort of the NP involved. One option might have been to put the patient in an ambulance and hope she made it to the nearest obstetrician, 55 miles away. To quickly review your options, and decide to buck up and do the best you can, is an ethical one.

The same situation applies in Amy’s case when she had to staple a patient’s scalp without anesthesia. Before proceeding, she quickly explained the situation and gave the patient the option to say no. Not exploring the wound first was an understandable breach in care; therefore, in the patient’s interests, Amy called the trauma center to make sure this had been done prior to his discharge.

Taking call in a frontier practice involves the ethics of availability. Pam stated that she had a response time of 20 minutes, so she ensured she stayed in a location that made this timeframe possible. Bob talked about staying up all night (being available) with a myocardial infarction (MI) patient at his clinic, while Jim stated that he was always cognizant of his 15-minute response time when he was on call.

The ethics of availability extends to the concept of access to care or distributive justice. Bob implies that the discontinuation of 24/7 medical service in his community was an unethical decision, based on finances and not service. Pam clearly felt it was unethical to close clinics in communities that had no other access to health care services and shunt the money to larger communities that had many health care options. Pam also thought it was unethical not to have local mental health services available for the little girl who had been raped.

Participants also provided evidence to support the ethics of stewardship. NPs were cognizant of the strain some patient situations placed on resources in their community. They were also aware of this concept in an economic context when discussing the expense of treating cases in an emergency room that could have been managed in their clinics for significantly less money.

Professional ethics are involved in protecting confidentiality in frontier communities. The first awareness of this comes with the effort the participants made to protect the identity of their communities and, hence, the privacy of their patients. The theme there’s an art to it refers to both the art and ethics of frontier NP practice. In many situations these are related. When faced with patients who would discuss private matters in public places, confidentiality may be breached. Preventing this breach of ethics without offending people is both an ethical decision and an artful skill developed by frontier NPs.

Out on a limb describes how frontier NPs can feel when faced with difficult situations. Deciding when to stitch a face or sew up a finger is an art which is developed by getting a feel for both the situation and the people involved. Giving people the news, deciding when and where to tell a patient that he or she has a terminal diagnosis, involves the art of nursing. Although all nurses and NPs are faced with ethical situations, this book brings the contextual ethical nuances of frontier NP practice to light.

  PERSONAL CHALLENGES

This section presents evidence related to personal challenges faced by frontier NPs. Stress related to personal challenges may affect both the NP’s professional and personal life. Retention of frontier NPs may hinge on the individual NP’s ability to cope with the challenges that accompany practice in the frontier, including adapting to the frontier culture or way of life. This involves a lack of anonymity and a blurring of social roles. These challenges were echoed in the narratives. Specifically, challenges related to being on call or on duty were noted by the participants. These challenges make it difficult to maintain a work–life balance that is conducive to one’s personal mental health and healthy interpersonal relationships.

Dual relationships within the community can be challenging as well. Finding a balance between the stress of having family and friends as patients and the comfort of “being there for them” may take time and experience. In Sharp’s study (2010), some NPs were not able to manage this aspect of frontier NP practice and therefore separated themselves from the community.

Frequent call duties are also a personal/professional challenge. It was evident in both Bob’s and Ann’s narratives that maintaining enough providers to share call was a priority. Call was also a factor for Jim, although in his situation, call was spread evenly among five providers, which made it more “palatable.” Lori noted that frontier NP practice was not always “rosy,” and that the long hours and call responsibilities made frontier practice challenging. The participants in this study have found strategies to cope with these challenges. Successful utilization of techniques mentioned in the narratives, such as wearing scrubs while on duty, leads to retention of providers. This in turn improves the health outcomes of frontier communities through access to local health care.

  THEORETICAL CONSTRUCTS

In addition to concepts and narrative themes, there are theoretical constructs woven throughout the narratives. A construct is a highly abstract concept that cannot be measured or observed (Chinn & Kramer, 1999, p. 56). Constructs may have multiple meanings; their meaning can only be determined in the context in which they are used, in this case frontier NP practice. The theoretical constructs in the model are characteristic of the environment of frontier NP practice; they represent the geo-socio-psychological environment of frontier NP practice.

Two assumptions related to theoretical constructs were made for this book. First, the theoretical constructs evidenced in the narratives exist on a continuum. For example, the construct independence exists on a continuum from slightly independent to highly independent. Second, individual thematic constructs may be related to other constructs. For the purposes of this book this relationship will be expressed by a forward slash (/). Four theoretical constructs emerged from the narratives: independence, fear, intimacy, and isolation.

Independence/Fear

Independence is a word used repeatedly throughout the narratives. The need for independence was the motivating factor that sent both Bob and Amy into the frontier. An independent practice was implied in all the participant stories. Even Jim, who worked in a group practice, worked alone when he was on call. He described patient situations when he was handling ER emergencies independently.

Fear was explicitly mentioned by Bob when he used the word “scary” to describe an obstetrical emergency. Ann also stated that potential NP candidates were “frightened immediately” when they learned what the job expectations were. Fear was implicit in Ann’s and Amy’s stories involving emergency patient situations. In most of the narratives, fear can be attributed to the lack of professional support during emergent patient situations.

The participants’ experiences indicate a relationship between the constructs of independence and fear. The more independent the practice, the more likely you will be presented with situations that are scary. Embedded in the construct of fear is the feeling of being out on a limb, a theme that emerged from Ann’s and Lori’s stories. It is the ability to overcome fear and act, or, as Amy states, “to make a decision” that leads to effective frontier practice.

Intimacy/Isolation

Intimacy and isolation may be considered constructs on opposite poles of the same continuum. Intimacy implies closeness or connectedness, whereas isolation implies aloneness, separateness, or nothingness. Isolation may be explicit, such as when used in the geographic sense, or implicit, when used in the psychosocial sense.

Intimacy is a theme woven through many of the stories. Bob states, “You get to know these people on a very intimate level,” and Jim was surprised at how intimate you get with somebody else’s life. Sue discusses the closeness that is a part of rural culture, the closeness which allows her to “cry with her patients.” Pam talks about how nice and helpful rural folks are to strangers. A sense of closeness or connectedness is implied in the theme reciprocity of care, such as when Pam finds a Thanksgiving feast in her motel room or when Ann is offered the use of restrooms during home visits.

Isolation is also a theme woven through many of the narratives. For example, a long transport distance to reach a higher level of medical care was mentioned by all the participants. This supports the concept of the geographic isolation of frontier communities. Isolation is also one of the criteria for federal designation of frontier communities. The theme flying solo, from Bob’s narrative, speaks directly to being on one’s own, or alone. Bob also talks about being kept socially aloof at community events. Ann talks about the lack of other health care professionals in her community, Sue talks about combating professional isolation by precepting NP students, and Amy discusses handling emergency situations without backup. Pam talks about driving through isolated areas, traveling to and from frontier clinics.

Intimacy and isolation are related concepts embedded in the narratives. Participant stories indicate that the intimacy they experience with their patients may be partially rooted in geographic isolation. Therefore, intimacy may be the trade-off or benefit derived from isolation.

  CONCLUSION

An analysis of the narratives revealed many interrelated concepts. Themes that emerged from the narratives exemplified some of these concepts. Both the themes and concepts represent different types of knowledge that frontier NPs use reciprocally to provide care for their patients and support their communities. This knowledge supports a model for effective frontier NP practice, a model that will be introduced in Chapter 12.

  QUESTIONS FOR DISCUSSION

         •   The analysis of narrative evidence is partially accomplished through interpretation of meanings. Are there any additional concepts or themes that reveal themselves to you?

         •   Historically, how have nurses used political knowledge and influence to impact practice?

         •   Think of a recent patient situation that you managed. What ways of knowing or types of knowledge did you utilize?

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