I grew up in a small town of about 5,000 people. I was in a hurry to grow up, spread my wings, and get as far away from there as I possibly could.  I often times told my parents there was no way I would live in a small town like this when I grew up.  You can imagine my surprise (and no doubt my parents’ surprise) when I found myself moving back to the area of my hometown just five short years after leaving it to go on to bigger and better things.  It is funny how your outlook on life and priorities change as we age. 

Throughout nursing school I never once thought about the idea of working in a small hospital. I imagine this is because all my experiences in nursing school were at a large university teaching hospital and other urban settings in the community.  And since there was no way I was going to live in a small town when I grew up it never really crossed my mind.  I never had the opportunity to experience rural healthcare prior to finding myself employed in a rural critical access facility with just 25 medical/surgical patient rooms, a three-bed obstetrical department, and a three-bed emergency department.  What did it really matter though? If I can successfully work in at hospital with more than 600+ beds, I surely can handle working in one with just 25. 

In all honestly, I hate to admit it, but when I first started working in a rural facility I was a little embarrassed.  All of my nursing school friends were working in large urban hospitals…NICU, SICU, MICU, and here I was working in a little ol’ hometown hospital.  At the time, I honestly thought that the nurses that worked in these hospitals were less intelligent, less skilled, and didn’t measure up to my friends that were working in these larger hospitals.  Boy, was I wrong!  To say the least, that ‘reality shock’ that we talked about in the previous blog post was back…and bigger than ever!

Can that happen? Can you have reality shock even after having a year or so of “experience” under your belt? I firmly believe that you can honestly experience reality shock any time you change positions in your career.  In this case, the bigger the change, the bigger the shock.  There is still that discrepancy between what you imagined your work to be like and what you actually experience which is the reason we experience these shock moments. 

For me, much of the shock stemmed from the limited human resources that are available to those working in a rural hospital.  For instance when I started, depending on the patient census, the minimum number of staff available on any given shift was three.  That is staff - not registered nurses. Therefore, a somewhat typical night shift included myself, one other nurse, and a nursing assistant covering the inpatient unit, OB, and ED.  There wasn’t a physician in-house, but on call with a 30 minute response time.  Ha!  Did you see that? Night shift!  I wasn’t able to entirely avoid them.  That should make some of you sleep a little better knowing that despite my best efforts, I eventually had to give in and work the overnight shift. 

Anyways, shortly after starting in my small hospital they were doing a monthly training which they called ‘mock codes’.  They practice code situations regularly because luckily they don’t occur all that often, but still need to be prepared for when they do. I had never experienced a code situation up to that point and I hadn’t yet taken Advanced Cardiac Life Support because working at a large hospital on a non-cardiac floor they told me I didn’t need to.  All I knew up to that point was if I came across a code situation was to hit the code button and begin CPR as quickly as possible. To make a long story short, I went in for my ‘mock code’ and was given a scenario that I come across a patient that wasn’t breathing and didn’t have a pulse (as if you didn’t see that one coming).    They asked me what I would do from there to which I responded, “I call the code team and begin CPR” to which they responded “Honey, you are the code team.” And all I could think was, what do you mean I am the code team? I am just one person!

When I worked in a large facility I had many human resources that I could call on if I needed help.  Code blue?  Call the Code Team. Patient not doing well, but not yet coding? Call the Rapid Response Team.   Unruly patient who wants to assault me or my CNA? Call the Restraint Team.  Hard IV stick? Call the IV Team.  These were specialized teams of people who had extra training, skills, and experience in these various situations that you can come across as a clinical bedside nurse.

Remember how at the beginning of this post I admitted that I was slightly embarrassed to be working in this little hospital? It didn’t take me long to realize how terribly wrong I was.  I don’t think nurses working in small hospitals are given enough credit.  In any given week, any individual nurse might have to labor a mom, resuscitate a newborn baby, care for a five year-old patient with pneumonia, a 30 year-old with appendicitis, a 60 year-old with an MI, or an 80 year-old as they take their last breath.  These nurses need to be experts at everything from bringing new life into this world to comforting one as they exit. They treat cardiac patients, respiratory patients, pediatric patients, obstetrical patients, surgical patients, trauma patients, and everything in between.  They are asked to seamlessly flex from one to the next.  After 5pm they are also pharmacy, materials management, housekeeping, dietary, and administration.  These nurses do all this and then fill the role of Code Team, Rapid Response Team, IV Team, and Restraint Team, among many other things I failed to mention.

Can you imagine starting as a new graduate nurse in a rural facility and being handed all of that responsibility in a relatively short amount of time? The concerns with workplace stress, role transition, lack of confidence, and struggles with organizing and managing workload can only be magnified by the feelings of needing to be an expert – not just in one area, but many, along with the multiple hats those in rural facilities are expected to wear.  On top of all that, these new nurses starting in rural facilities are usually one of just a few nurses hired in an entire year. Therefore new nurses starting in these facilities have no way of knowing that what they are experiencing is completely normal because there typically isn’t someone having those same experiences simultaneously.  The isolation only amplifies the stress, shock, and feelings of inadequacy. 

Nurse residency programs have proven to increase confidence, competence, and moral, along with enhanced patient safety, and cost savings derived from decreased expenses associated with recruitment and orientation of replacement staff. But why should that be limited to large urban facilities? This is why the Iowa Online Nurse Residency Program was developed.  While it can meet the needs of even a large urban hospital, it was the volume of rural facilities in our state that fueled the need to develop a turn-key program that can be used when you are only hiring one nurse at a time.  Nurses enrolled in the online option of the program have the opportunity to become a member of a group of new graduate nurses that are starting in similar hospitals all over the United States.  They get to chance to hear what it is like to work in a rural hospital in Idaho, Nebraska, or Texas to name a few, all from their computer.  Not only are they provided with the opportunity to receive peer support, but the program also covers competencies that research has shown to be lacking when new nurses arrive to practice.  It also gives the new nurse the opportunity to make a meaningful difference on their units through the completion of a residency project, which is an expectation of Millennials entering the workforce.  We believe it shouldn’t matter where a new graduate nurse chooses to practice early in their career - each one should be provided with the tools and support needed to be successful.  By providing this program to your rural nurses you will help to set the stage for a strong and engaged workforce, providing the highest of quality in the rural setting. 

Nicole Weathers, MSN, RN
Program Manager-Iowa Online Nurse Residency
nicole-weathers@uiowa.edu