Understanding the Lived Experiences of Nurses Working in Critical Access Hospitals 111
In 1997, federal legislation was enacted as part of the Balanced Budget Act which authorized States to create a State Flex Program. The State Flex Program allowed certain healthcare facilities participating in the Medicare program to become Critical Access Hospitals (CAH). Critical Access Hospitals are hospitals certified to receive cost-based reimbursement from Medicare. This reimbursement is intended to optimize their financial performance and decrease hospital closings. Currently, the state of New Hampshire has 13 hospitals that have been designated as Critical Access Hospitals (Rural Assistance Center, 2014). Every CAH must meet federal standards in order to maintain this special designation. These standards include a rural location and the provision for 24-hour, 7-day-a-week emergency care services for patients of all ages and with varying types of medical and psychiatric needs. Critical access hospitals in New Hampshire provide local residents and tourists with a variety of health care services, some of which are related to primary care, while others involve life-saving interventions. The nurses working in these rural areas are expected to demonstrate excellence in clinical decision making and to function as independent practitioners meeting the holistic needs of patients of all ages (Hurme, 2009). However, there is a gap in the literature related to the lived experience of nurses working within these settings. Examining how nurses in CAHs perceive their role and experiences will provide insight into the systems necessary to support the professional and practice needs of this unique cohort of nurses.
Key Words: Rural Nursing, Critical Access Hospital, Descriptive Phenomenology.
I. RESEARCH AIM
The purpose of this descriptive, phenomenological study is to gain an understanding of the lived experience of nurses working in critical access hospitals through the identification of essential themes.
II. THEORETICAL FRAMEWORK
Phenomenology is both a philosophy and a research methodology (Grove, Burns, & Gray, 2013). The goal of this research method is to determine whether daily occurrences may be indicative of patterns or structures of phenomena as experienced by human beings interacting with each other and their environment. Refinements in methods and processes of phenomenological inquiry have been modified during recent decades to include further precision and diversity in methods of data collection and analysis. The philosophical positions of phenomenological researchers (Colaizzi, 1978; Giorgi, 1985; Husserl, 1965; Merleau-Ponty, 1956) differ from those based in the quantitative sciences and nursing fields, which often prescribe large samples size and generalizability of findings (Burns, Grove, & Gray, 2013). Colaizzi’s method of phenomenological psychology served as the theoretical underpinnings for this research. Colaizzi was an existential phenomenologist who proposed that in order to best understand a human experience researchers must connect with that phenomenon as people experience it (Colaizzi, 1978). He believed that the phenomenologist must begin research by first examining his/her approach in order to uncover preconceived notions or biases about the research topic (Valle & King, 1978). The questioning of these presuppositions about a phenomenon can lead the researcher to discover certain hypotheses, values, and attitudes that provide a foundation for the formulation of research questions.
Qualitative researchers support the use of phenomenological methods of inquiry because they are ideally aligned with the principles of the health sciences, where creativity and self-actualization are valued, and knowledge of a person’s unique experience is accessible through conversation (Kim & Kollack, 2005; Solomon, 2001). Phenomenologists subscribe to the notion that the true meaning of a phenomenon is rooted in the daily experiences of human beings. The interaction of these human beings is the essence of truth. Phenomenology explores these truths through a specific, rigorous process of self-examination (Sokolowski, 2000).
Colaizzi (1973) stated the success of all phenomenological research questions depends upon the degree to which they capture the participants’ experiences of the phenomenon as unique from their theoretical knowledge of that phenomenon. Therefore, if the questions are formed to capture the essence of the experience in question, anyone who has experienced the phenomenon and can intelligently communicate that phenomenon may serve as a research participant.
Once the subjects’ responses have been collected, Colaizzi suggests seven procedural steps that will allow the researcher to phenomenologically analyze the information. Step 1 involves reading the subjects’ transcripts, which are termed “protocols,” in order for the researcher to gain a feeling and understanding of the meaning behind the words. Once the researcher has read through each of the protocols, the next step involves returning to the information to begin the process of extracting significance.
During Step 2 of the process, the researcher must meticulously review each protocol and extract significant statements. The significant statements are defined as those statements having bearing on the phenomenon being investigated. The researcher may find duplication or repetition of statements during this process, and if that occurs, repetitions can be eliminated. Quotations that may refer to specific events or feelings can be altered from a specific meaning to a more general formulation.
Step 3 of Colaizzi’s method requires the researcher to attempt to extract a meaning for each significant statement. This is a very creative process that requires a thoughtful review on the part of the researcher to determine the meaning behind the words of each research participant. The step is a precarious one because the researcher can risk losing a connection between the original protocols but at the same time stay within the boundaries of the subjects’ lived experiences.
Step 4 includes a process of grouping all of the formulated meanings from the significant statements into categories that reflect a cluster or theme. Each cluster must then be coded to include all potential meanings related to that cluster. Once that process is complete, groups of clusters of themes must be integrated to form a unique construct of theme. This requires that all themes be internally similar and externally different. Therefore, each created meaning must cascade into only one theme cluster that is distinguished in meaning from other constructions (Mason, 2002). escription.
Step 5 includes the defining of all evolving themes into a thorough description of the phenomenon being studied. Once this thorough description has emerged, the entire structure of the phenomenon of study becomes apparent. At this point in the process, the researcher may elect to have an expert researcher review findings to validate the richness and thoroughness of the process.
Step 6 encompasses the development of a complete description of the phenomenon of study in as unambiguous a statement of meaning as possible. During this process changes may be applied to elucidate clear relationships between clusters of theme and their extrapolated meanings. This may result in discarding some vague structures that do not add strength to the whole description.
Step 7 is aimed at validating study findings. The process of validating requires the researcher to return to the study participants. The participants are asked to review the transcript of their interview and validate the comprehensiveness of the transcript. Participants are allowed to provide additional information during this step or to refute any perceived errors in the transcription of the data.
III. REVIEW OF THE LITERATURE
Yonge, Myrick, Ferguson, & Grundy (2013) conducted a photovoice study to develop a narrative of teaching and learning practices of nurses in rural settings as seen through the lens of nursing students and their preceptors. The main theme of this project was that rural nurses transfer a strong sense of community spirit to practice. The findings from this research emphasize that teamwork and community spirit are key factors in promoting rural preceptorships and careers in rural and critical access healthcare settings. This project provided insight into the culture of rural nursing through the lens of “visiting” healthcare providers.
The scarcity of nursing staff and the budgetary constraints that currently exist in rural and critical access hospitals leads to reduced access for rural residents. A comprehensive analysis of constraints confronting nurses working in rural areas is needed (Conger & Plager, 2008). Using an interpretive phenomenology, the terminal outcomes of Advanced Practice Nurse (APRN) graduates was studied. The major theme that evolved from this research was rural connectedness versus disconnectedness. Conger and Plager (2008) identified the development of support networks, relationships with urban health care connectedness, and support through electronic means. The researchers emphasized that if nurses find that their initial experiences lead to feelings of disconnectedness, such feelings will discourage them from remaining in rural practice.
Drury, Francis, and Dulhunty (2005) interviewed mental health nurses working in rural areas of Western Australia concerning their everyday lived experiences related to their nursing practice. The purpose of the study was to determine whether Community Mental Health Nurses employed in the southwestern region of Australia encountered similar problems and role demands to those of generalist nurses working in rural Australia. The researchers utilized a hermeneutic phenomenological approach to ascertain themes related to the participants’ lived experiences. These themes included: holistic care of clients; isolation, autonomy and advanced practice; professional development and status recognition; educational support; and caseload nurses and caseload composition. Findings from the research indicate the complexities of the role of these nurses, including local knowledge, awareness of community resources, therapeutic interventions, and support to other clinicians. These findings support prior research regarding the enhanced role of generalist nurses in rural Australia (National Rural Health Alliance, 2002).
Due to the paucity of research related to the lived experiences of rural nurses this research is necessary to gain insight into this phenomenon. The knowledge, skills, and attitudes of rural and critical access nurses must be aimed at making remote and rural nursing a place where nurses not only wish to gain employment but also want to continue to work within (Hegney, 2002). In order to achieve that aim, nurse researchers must add to the body of knowledge regarding the lived experiences of critical access nurses and ascertain the impact that culture may have on the lived experiences of rural nurses.
A descriptive design was employed, using Colaizzi’s method of descriptive phenomenology. Following approval by the Investigational Review Board at Southern New Hampshire University (#2013-022), the chief nursing officer from a local rural access hospital in New Hampshire was contacted and permission was sought to recruit registered nurses from the staff for participation in the study. The institution that served as the recruitment site for this research met the Critical Access Hospital Designation as defined by the Department of Health and Human Services Centers for Medicare & Medicaid Services (2014).
The sampling method that was chosen for this study was a purposeful sample. This allowed the researcher the ability to travel to the site for the initial recruitment, data collection, and verification of participants’ transcripts. The location that the sample participants were recruited from was a critical access hospital in New Hampshire. The study participants were informed of two recruitment sessions that were scheduled at the hospital through the use of a flyer which was posted throughout the hospital. The researcher felt it was important to hold one recruitment session on a weekend day so that part-time staff would have the same opportunity to participate in the study as full-time staff. The participants were given copies of the Informed Consent document during the recruitment sessions, and they were encouraged to ask questions regarding the study’s purpose, the required time commitment of participants and any other questions that they may have regarding study procedures. Ultimately, four registered nurses agreed to participate and signed the Informed Consent document.
VI. DATA COLLECTION AND SURVEY QUESTIONS
The participants were each scheduled for a 20-30 minute initial interview. These interviews were held at the critical access hospital, in a private conference room. The participants self-selected the day and time of the interviews based upon lunch breaks, personal time, or after the end of a workday. During the initial interviews each of the subjects was asked to respond to the following questions:
How many years of nursing experience do you have as a registered nurse?
- What is your educational background? Are you currently matriculating in a program to continue your nursing education?
- Can you describe the various settings that you have worked in other than your current position?
- What is your current position? How many hours per week do you work?
- What is it like to work in a critical access hospital?
- Tell me about your nursing practice. Using Benner’s (1984) model of novice to expert, how often do you feel good about your experiences at work? Please explain.
The second interviews were scheduled within 2-4 weeks of the initial interviews. During the second interviews the subjects were provided with written copies of transcripts from their initial interviews and asked to validate the text and meaning of their responses.
6.1. Data Analysis and Interpretation.
Themes were identified using bracketing analysis, which involved listing patterns of experiences from the transcribed interviews on index cards, identifying data that related to the classified patterns, and tagging these patterns into trends. Coding and bracket analysis revealed four essential themes, and they were:
Participants related their feelings of extreme responsibility, which they felt toward patients, family care providers, and coworkers while providing care and comfort to patients recovering from trauma, multi-system organ failure, childbirth, and hospice care. Participants’ statements included: “Our patients are our neighbors, friends, and family. They are cherished members of our community. It really takes a village to provide patient care in this setting, and that is who we are.”
Participants emphasized the importance of mentoring, despite the absence of a formal mentoring program or curriculum. Some of the participants recalled stories of being mentored, while other participants recalled stories of mentoring novice nurses. “I consider myself one of the experts here in providing nursing care. Part of my obligation as an experienced RN is to give back to my profession and mentor new graduates. I learn as much from them as they learn from me.”
Participants related their feelings of isolation from their local peers and their peers in the greater nursing community. “I am very content with my peers, but it is at times a struggle especially in the bad weather to attend conferences and meetings beyond the local area. I don’t think that my peers in the bigger hospitals understand or value the uniqueness of what we do.” All of the participants are members of at least one local service organization and held memberships in at least one professional organization.
Although each of the participants had her own definition of spirituality, they all mentioned the spiritual nature of their roles in nursing and the impact that spirituality has had on their ability to manage the most stressful of situations. “At the end of each shift I meditate on the care that I have provided to each patient and consider how I could improve my practice.
The aim of this study was to understand the lived experiences of nurses working in critical access hospitals and the aim achieved. However, the limitations of the study must be acknowledged. The sample size was small and taken from one critical access hospital located in a small region of a New England state. Due to a gap in the literature in the roles, responsibilities, and support mechanisms available to nurse generalists in rural areas, comparison of this information to evidence-based literature was a challenge.
VIII. RECOMMENDATIONS AND CONCLUSIONS
This study has confirmed the literature findings regarding the multifaceted issues that nurse generalists working in rural health settings face on a daily basis. In the United States, these nurses provide the only access to healthcare for one in five residents living in rural communities (Moscovice & Stensland, 2002). This research study provided a glimpse into the lived experiences of nurse generalists working in a critical access setting. Replication of this study is needed in order to gain a better understanding of the themes identified in this study.
In order to demonstrate excellence in patient-centered care and safety, these nurses need access to education and support programs that formally recognize the uniqueness of their nursing roles. Nursing leaders in patient care and academic settings must engage in research that will provide a greater insight into the lived experiences of nurse generalists working in rural settings in order to better understand the supports they need to continue their practice.
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