By Kay Miller Temple, MD
This story originally appeared November 10, 2020, in The Rural Monitor, at the Rural Information Hub.
In August 2019, the University of South Carolina Arnold School of Public Health Rural and Minority Health Research Center published results from a national web-based survey focused around nurses’ personal perception of training preparedness. Out of 435 respondents, 72 identified themselves as rural nurses, 42 working in the ambulatory setting. Of the rural respondents as a whole, approximately 11% held diploma degrees, 11% held associate degrees (ADN), 27% held bachelor’s degrees (BSN), and 40% held master’s degrees (MSNs). The study’s raw data indicated that about 85% of rural nurses felt their training prepared them for their job, compared with around 94% of suburban and urban nurses.
As a nursing doctoral candidate at the University of Wisconsin-Madison School of Nursing and member of the Rural Nurse Organization, Jennifer Kowalkowsi is not just aware of rural nursing preparedness and results as noted by the South Carolina researchers, she is working to remedy that disparity with her research efforts. She realized this was a unique focus when she tried to find academic collaborators on her own campus — and in other areas of the U.S. — with similar research interests.
“I’m working on educational content that promotes an understanding of what influences rural health disparities, why those influences impact rural health outcome measures, and how training registered nurses to meet the demands of caring for rural populations can help decrease those disparities.” —Jennifer Kowalkowsi
Kowalkowski said her passion for the work starts with the story of her own rural roots as a member of a fourth-generation Wisconsin dairy farm family.“I’m interested in creating best practices for educating undergraduate nursing students in the nuances of rural health,” Kowalkowski said, “To elaborate, I’m working on educational content that promotes an understanding of what influences rural health disparities, why those influences impact rural health outcome measures, and how training registered nurses to meet the demands of caring for rural populations can help decrease those disparities. There aren’t many other nursing researchers currently in this space.”
“I grew up wanting to be a veterinarian,” she said, sharing a pivotal anecdote that happened when she was 16. “One day, a heifer went through me, not around me, and I thought, do I want to really spend my days endangering my life with taking care of animals so much bigger than me? I’m short and I’m not going to get any taller.”
Leaving veterinary dreams behind, she eventually chose another caring profession: nursing. As a registered nurse (RN), she provided direct patient care in critical care units and also provided palliative care. Although she worked in urban locations, her care assignments always included rural patients. She understood the multiple factors associated with their healthcare access issues and she understood their work environments. She said as she listened to providers who’d never been in rural areas provide advice, education, and follow-up instructions — many of the elements associated with health disparities — she realized there was a major opportunity to make a difference for nursing professionals to more closely align those words with the realities of rural living.
From across the country, other registered nurses in leadership and educational positions shared their stories. Read more in Rural Registered Nurses: Stories of Caring for Their Communities.
Now in a doctoral program in order to make that difference with her research and student teaching, Kowalkowski said she is grateful for the overwhelming support of her academic advisor and other nursing school faculty members. Because of that support, she was able to engage in a 2018 quality improvement project that involved 63 nursing leadership members from a Wisconsin rural health network co-op, 15 academic faculty, and 28 nursing students. Data were collected from online surveys as well as face-to-face interviews. Elements of the research were:
- Use of the stakeholder engagement process, an evidence-based method for identifying and addressing shared priorities
- Labeling educational needs as a theory-practice gap
- Understanding faculty and co-op nursing leaders’ personal rural experiences in order to influence and strengthen curriculum development
Figure 1. Competency Comparisons.
Her work, summarized in a poster presentation for the 30th International Nursing Research Congress, also included an examination of existing nursing competency standards with respect to rural practice preparedness (Figure 1). Competency standards were based on the AACN (American Association of Colleges of Nursing) Essentials, a broad literature review, and competencies suggested by rural nurse preceptors themselves. With the exception of safety and physical assessment, nursing faculty rated preparation of nursing students for rural practice higher than the rural co-op members for all competencies. A statistically significant difference was found between the ratings of nursing faculty and rural practicing nurses for seven of the 12 professional competencies. Three of those seven were critical thinking, clinical judgement, and intraprofessional communication.
Her research also included looking at the student nurses’ perceptions of rural areas in general.
“It was especially important to formally evaluate nursing students’ perceptions of their training and their perceptions of rural culture,” Kowalkowski pointed out. “Since I grew up as a fourth-generation Wisconsin dairy farmer and am now in the position of interacting with nursing students, being able to quantify and qualify this information becomes important for efforts focused on increasing a prepared rural nursing workforce.”
For example, student nurses shared that after learning and working in rural locations, they found that a rural environment allowed a broader use of their skills, increased practice autonomy, yet support when needed, and that good employment opportunities existed in rural areas (Figure 2).
Figure 2. Student nurses’ perceptions of rural living and work opportunities.
Kowalkowski said that with project completion, participants recognized its scaleability — especially important in view of regional variation across rural America. She said she was also pleased that results are being used for additional work.
“I’m finding that the results are being used to bring increased awareness of agricultural-related health and well-being in Wisconsin,” she said. “They are also being used to help design policy and fund advocacy approaches to support rural nursing clinical experiences and develop nursing faculty with rural expertise. You can’t have more rural nurses without having nursing faculty to educate them. It’s important to not lose sight of that.”
To continue reading this story, and profiles of three more rural nurse researchers, visit Rural Information Hub.