Opening farm gates: community as educator

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We are five undergraduate students completing the pre-registration Bachelor of Nursing degree at the University of Tasmania. As the sole provider of nurse education in Tasmania, the broad objective for this program is to prepare students with a generalist knowledge base to competently practice in a broad spectrum of first level roles in a variety of clinical contexts¹.

During second year, the rural placement program is an extension of a yearlong clinical based unit, known as Supportive Care in Hospital and Community Settings. This unit aims to build upon the first year introductory units that focus on primary health care and health promotion by shifting the emphasis to nursing in community and clinical environments. Throughout this unit the emphasis is on extending our theoretical understanding of nursing while engaging in clinical practice within a hospital environment, including the rural setting.

We were randomly selected to undertake our clinical practice rotation in a rural environment. Only two students in our cohort had ever lived in a rural area. Rural nursing was not a career priority at the beginning of clinical practice. We were primarily concerned with surviving our first experience of nursing, completing our assessment requirements, and developing clinical practice knowledge and skills along the way. An unexpected corollary however was the overwhelming influence this positive experience had on our broad perceptions of rural health care and increasing our interest in rural nursing as a future career option. This fact is frequently reflected in the literature^2-6.

In search of other students' rural experiences we were dismayed to find a paucity of literature written from the perspective of the student. This however served as the impetus for us to document and present our rural placement experiences. This paper will critically discuss how the community contributed to our education and shaped our views on possibly pursing a career in rural nursing.

Cows and fences

...no MacDonalds, no movies, no nightclubs, lots of cows, lots of fences, lots of green pastures, freshness, freedom...

Our journey began in a classroom where our lecturer announced the clinical placements for our first rotation. The placements were divided into two areas, with one cohort being allocated metropolitan health care agencies, and the other allocated rural-based placements. We eagerly awaited our first experience of nursing in an actual health care environment, but had some trepidation of undertaking our placement in a rural community.

An avalanche of thoughts and images about how rurality might influence our clinical experience were triggered by the news of having to go to Scottsdale, a small town in the north of Tasmania. As with all situations there are negative and positive aspects of rural health care practice⁴. From the undergraduates' perspective the disadvantages are more prominent and immediate than the positive aspects. The issues that sprang to mind centered on how would we cope in this strange environment.

Imagery of grazing cows synonymous with the laid back atmosphere symbolic of rural communities were our first impressions. Nevertheless, one early autumn morning we set off on the journey to Scottsdale. Watching for directional signs we quickly became entranced by the sheer beauty of the changing landscape. Before long we broached the crest of the hill to see an opening vista and Scottsdale suddenly appeared. Looming in the distance were grain silos and an array of farm machinery. We had an acute sense of being outsiders entering through metaphoric farm gates.

Beyond the gate

...pulling my jacket tightly to brace against the chill I stood outside the teaching site enjoying the fresh air while pondering my direction...right, up the hill to the hospital...or left, down the main drag to town.

We undertook our clinical placement at the North Eastern Soldiers Memorial Hospital (NESM), which is the sole provider of acute health care for the Dorset municipality. The diverse hospital services provided to the community are supported by a variety of health care professionals and visiting specialists. As a hub for rural health care services in the Dorset region this is an ideal place for students to understand and be involved in the comprehensive nature of rural health care. During our placement we lived at the Scottsdale Rural Health Teaching Site (RHTS), which is the largest facility in the University Department of Rural Health (UDRH) network of learning environments dedicated to rural health teaching, learning and research.

Embracing outsiders

Ill equipped for the extreme fatigue shift work and the busy ward environment would cause, we found ourselves in the bakery giggling madly behind cupped hands like silly schoolgirls. The young girl serving us smirked as she watched - she must have thought we were quite mad. Waving our hands through the air we said, 'Don't mind us we are nursing students.' We were shocked to see her glance at her colleague then look back at us to nod and casually reply, 'We know!'

On our journey to becoming nurses, we felt as though we were sitting on the perimeter of nursing, and that we were outsiders to the community. Scottsdale has been facilitating health professional students throughout their rural rotations for some time now. The community are used to transient cohorts of students around town. The people exhibited a nurturing spirit that quickly embraced us. We became affectionately known as the 'nursing students', which was comforting and welcoming.

Despite feeling secure in this environment, we were aware that our anonymity had vanished and our presence in the community was quite visible. This realisation had huge implications on the way we felt we had to behave in public. It soon became apparent that, in Scottsdale, health care professionals were highly regarded. We were aware that our social behaviour was under close scrutiny and would ultimately reflect on our professional identity. In this regard we felt we had a responsibility to project an image of professionalism at all times, inside and outside the hospital.

Interwoven nature of rurality

...she is engaged to the guy who drove the ambulance, he works as the maintenance man, her mother is a cleaner...who is related to one of the patients...who is friends with the kitchen lady...

Regional hospitals service the health care needs of communities within their local municipalities. The nature of rurality extolled by rural people is that there is an acute sense of belonging with a strong allegiance to local kinship and family. As a consequence, there is a keen interest in local issues which gives rise to many individuals being privy to intimate information about others. This phenomenon presents providers of health care with a double-edged sword: nurses may have additional, sometimes intimate, knowledge of their patients, but the patients often have similar knowledge of the nurses! As newcomers to this environment we were mindful that patients, staff and visitors to the hospital are all members of the rural community and are often inter-related.

As nursing students, this distinctive feature of rural life gave rise to two main issues. First, we recognized that, as a professional, protecting the privacy of patients is essential. Within a rural hospital, however, patient confidentiality requires more conscientious attention. Second, health care professionals are recognised and may be known personally by local people. Because of this, the nursing identity transcends professional practice to invade personal life.

In fact, we have decided that working as a nurse in a rural setting comes with a responsibility to continuously behave as a professional. This has huge implications for us in terms of wishing to become rural nurses. We began to consider how our lives might change should our professionalism be on continual display, and questioned how much of our personal lives we would be willing to share as local knowledge.

Likewise, we began to wonder at what point we stopped being nurses and became people again. We questioned whether rural nurses ever really do have time out from their careers. In spite of these obvious drawbacks, many rural nurses live in rural communities in order to reap the rewards of knowing their patients and families intimately⁷. For us, the lack of privacy and timeout would make returning to a rural community to pursue employment as a graduate a challenging decision.

Joining the community

...what is going on here why would a stranger invite all of us to dinner to share her roast lamb...

'Challenging' is precisely the reason why health professionals are attracted to working in a rural setting. Hospital workers in rural settings are required to be multi-skilled⁷ with a role that often advances beyond the usual realm of nursing practice⁸. During our placement, we saw patients present with a diverse range of illnesses and conditions. We saw nurses become ambulance officers, respite volunteers, gardeners, paediatric and midwifery specialists, and aged care specialists - all in the span of one shift! To say the least, our clinical practice experience was wide and varied, with a vertical learning trajectory. We were impressed at the rural nurses ability to adapt to the many and varied situations, often at a moment's notice. With limited support services to rely upon, the rural nurses were self-reliant and forced to initiate and implement many services on their own. In this regard,we feel rural nursing has so much to offer a new graduate seeking to develop professionally as a generalist nurse.

The interdisciplinary collegiality we experienced during our placement was incredibly reassuring. The mutual respect the rural health care professionals displayed toward one another provided us with a comprehensive benchmark for our future involvements with those working in other health professions. Underpinning these professional relationships was a high degree of respect. This respect extended to the wider community. In fact, this was the big lesson the community imparted to us: rural people care about one another.

It was not until we returned to the faster paced urban setting that we realised the full impact of our experience. For one of us in particular, this consciousness was particularly reflective. She explains:

...my first night back in Launceston I went to an event at the Princess theatre and a sea of unfamiliar faces surrounded me, suddenly I felt very alone and felt compelled to go back to Scottsdale.

On the whole, we missed our sense of belonging to the rural community, and began to regale the notion of perhaps working in a setting such as Scottsdale. We began to consider our initial concerns of living and working in a rural context and started to rethink them from a different perspective. Our reservations about leaving the modern conveniences of urban life were quickly replaced by enjoying the experience of freedom and relaxation. Our previous perceptions of a nosy, prying community became, instead, notions of a caring community that whole-heartedly embraced us and welcomed us into their environment.

More importantly however, our ideas about rural nursing being slow and un-interesting were replaced with a newfound respect for practice that demands skill diversity, flexibility, and is underpinned with a strong sense of self-reliance and dependability. So, even though the close rural community can at times seem stifling, at the same time it creates a very comfortable security blanket that can become rather addictive. After all, we all like to be known, and we all need to feel secure with our place in society. Since completing our rural experience, we are left with positive imagery of our time there and cannot rule out the possibility of returning one day to work as rural nurses.

Rural health care is more that just a local population accessing health services through usual health care providers. Rural health care is about communities, and the existence of rich relationships within these areas. The role this rural community played in our student experience was active and prominent. It made a valuable contribution to our development as appropriately prepared future rural health care professionals by exposing us to the challenges and rewards of rural life.

References

1. University of Tasmania, Course Guide and Handbook. University of Tasmania, 2001.

2. Walker J. Addressing Rural Population Health Needs in a Teaching Program: Evidence as a Base for Learning. In: Proceedings, 5th National Rural Health Conference. Canberra. National Rural Health Alliance, 1999.

3. Rosenblatt R, Whitcomb T, Cullen T, Lishner D, Hart G. Which medical schools produce rural physicians? Journal of the American Medical Association 1992; 268: 1559-1566.

4. Peach H, Bath N. Comparison of rural and non-rural students undertaking a voluntary rural placement in the early years of a medical course. Medical Education 2000; 34: 231-33.

5. Loud J. Recent Graduate Preparedness for Rural Employment. In: Proceedings, 6th National Rural Health Conference, Canberra. National Rural Health Alliance, 2001.

6. Hollins J, Smith D, Pashen D, Chalmers E. Student evaluation of rural health placements: implications for remote education and health service providers. In: Proceedings, 6th National Rural Health Conference, Canberra. National Rural Health Alliance, 2001.

7. Mueller J, Stoeger M. These nurses do it all (rural nurses), RN 1995; 58: 41-43.

8. Pearson A. Expansion and extension of rural health workers' roles to increase access to health services in rural areas. In: Malco K (Ed) A Fair Go For Rural Health - Forward Together. Armidale, Australia: University of New England, 1998; 213-218.