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 possible. I often told my parents there was no way I would live in a small town like ours when I grew up. You can imagine my surprise (and no doubt my parents’ surprise) when I found myself moving back to my hometown, just five short years later, after leaving it to go on to bigger and better things. It’s funny how your priorities change as you get older.   

Throughout nursing school, I never once thought about the idea of working in a small hospital. I imagine this is because my experiences in nursing school were at a large university teaching hospital and other urban settings in the community. 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 a hospital with more than 600+ beds, I surely can handle working in one with just 25 beds.   

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 my little ole’ hometown hospital. At the time, I thought the nurses that worked in these hospitals were less skilled and didn’t measure up to my friends that were working in larger hospitals. Boy, was I wrong! The reality shock was staggering. 

Can that happen? Can you have reality shock even after having a year or so of “experience” under your belt? I believe that you can experience reality shock any time you change positions in your career. In this case, the bigger the change, the bigger the shock. 

The discrepancy between what you imagined work to be like and what you actually experience, can lead to reality shock. For me, much of the shock stemmed from the limited human resources that were available to me while 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 typical night shift included me, another 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. Despite my best efforts, I eventually had to give in and work the overnight shift.   

Shortly after starting, my small hospital offered monthly trainings called ‘mock codes’. We practiced code situations regularly, because even though they didn’t occur often, we still needed to be prepared for when they did. I hadn’t experienced a code situation 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 come across a code situation, I hit the code button and began CPR as quickly as possible. I went in for my ‘mock code’ and was given a scenario that included 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? I responded, “I would call the code team and begin CPR.” They responded, “Honey, you are the code team.” 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 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. As a clinical bedside nurse, I had access to specialized teams of people with extra training, skills, and experience in those various situations. 

Remember at the beginning of this post, I admitted that I was slightly embarrassed to be working in this little hospital? It wouldn't take me long to realize how terribly wrong I was. Nurses working in small hospitals are not given enough credit. In any given week, an 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 of 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. There isn’t someone having those same experiences simultaneously. The isolation only amplifies the stress, shock, and feelings of inadequacy. 

Nurse residency programs are proven to increase confidence, competence, and morale, 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 a large urban hospital, it was the volume of rural facilities in the state of Iowa 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 can 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 the chance to hear what it's 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. 

I 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 the IONRP to your rural nurses you will help set the stage for a strong and engaged nursing workforce, providing the highest of quality in the rural setting.

Nicole Weathers, Program Manager, IONRP nicole-weathers@uiowa.edu