Ethical Nursing Conflicts in Rural Health

Copyright: © 2017 Claudia C, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. *Corresponding author: Eldo E Frezza, Professor of Ethics and Law, Canseco School of Nursing, Texas A&M International University, USA, E-mail: eefrezza@msn.com


Introduction
According to the US Census Bureau, any community whose total population is under 50,000 is considered a rural area [1].Recent estimates indicate that nearly 25% of the total US population now resides in rural areas [2].Residents who live in these communities depend on healthcare workers to meet their medical needs in a timely and accessible manner.Since there is a significant lack of primary care providers working in rural areas, it is a constant battle for nurses to achieve success in the delivery of quality healthcare [3].Therefore, healthcare professionals including nurses must be prepared to multitask and possess the confidence to independently manage a multitude of patients living in rural communities [3].
Clearly, there is a little dispute regarding the stressors that create ethical problems for healthcare providers throughout their careers [4].When discussing the ethics of healthcare, the majority of attention has been focused on those who provide care in high acuity areas such as in hospital emergency rooms and intensive care departments.Rural health nurses must face unique geographical, cultural and socioeconomic challenges that can complicate the delivery of healthcare to patients and are unlike those of their nursing counterparts who work in more developed, urban areas [2].The most common themes that result in ethical conflicts experienced by rural health nurses include working with limited resources, lack of professional support and complex dual professional-patient relationships.Consequently, nurses in rural settings must be supported in their quest to identify sources of ethical conflict and ways to manage these problems in practice.The ethical base of nursing practice by the American nursing association (ANA) is outlined in Table 1.This paper will explore the main themes that have been identified by nurses as creating the most difficulty for the provision of adequate healthcare in rural communities and how to maintain ethical standards of practice as a rural health nurse.

Method
A literature review was conducted using both the CINAHL and PUBMED databases.An initial search yielded a total of 62 articles.Findings were then filtered to only include research articles written in English.For the purpose of this paper, 9 articles were used based on inclusion criteria of the date of publication and population focus.Key terms used to facilitate the advanced search option of the literature review included 'rural nurses' , 'rural health' , 'rural communities' , 'challenges or barriers to healthcare' , 'rural populations' , 'healthcare settings' , 'resource allocation' , 'medically underserved populations' , 'professional isolation' , 'professional boundaries' , 'boundary crossings' , 'nursing ethics' , 'ethical decision making' and 'ethical practice' .The publication dates for research articles used in the review of literature were between 2000 and 2015.The articles obtained from the review of literature included both qualitative and quantitative studies conducted in the US.The sample population for articles used rural communities within the US.However, three articles included nurses who practiced in the countries of Botswana, Canada and Wales.The definition of a rural community and statistics regarding rural population density within the United States was obtained from the US Census Bureau.

Results
Findings obtained from a review of literature conclude that ethical dilemmas related to nursing care in rural communities exist throughout Open Access 2 the world.In a qualitative study by Coyle [3], a convenience sample of 248 nursing subjects working in rural communities were surveyed to assess their opinions regarding health needs of residents.Survey results indicated that multiple barriers including professional isolation, lack of personal privacy, decreased access to educational advancement and limited resources all affect the quality of healthcare provided in rural communities [3].Similarly, a study involving Canadian rural health nurses determined that challenges such as limited resources and the lack of professional support created ethical challenges which interfered with patient care and negatively affected the well-being of patients [5].In a separate study involving interviews with 22 public health nurses, data suggested that nurses knew what had to be done to yield optimal patient results, but were prevented from providing care due to actual constraints [4].In an article on rural health nursing practice in Botswana, ethical issues arose from working within environments that had a shortage of nurses and an unequal distribution of health resources [6].In another study conducted in rural Wales, nurses stated that although working in smaller communities allowed for a more personal connection with patients, this connectedness also created an increased risk for potential boundary crossings related to privacy violations [7].Many patients living in rural communities fall below the poverty threshold and do not have health insurance [8] and therefore they rely heavily on nurse's care.The professional Development in Rural Nursing presents many: Challenges and Opportunities.Challenges are derived from working alone and facing new diseases presentation and opportunities to see pathology that nobody else is exposed too [9].The major hurtles in rural setting has been reported to be education and preparedness [10] given that many school do not prepare nurses for this challenge job.

Discussion
Most information obtained from the review of literature indicates that there were three common themes that surround ethical issues most often faced by nurses working in rural communities.The first ethical issue involves the unequal distribution of resources in rural areas.Yet it is these same patients that often require a higher level of care due to poorly managed health conditions [8].In addition, the shortage of healthcare providers who practice in a rural community places patients at a disadvantage since many will not readily have access to specialists who can provide care for their complex health needs.Healthcare providers must struggle to provide care to patients who would benefit greatly from being referred to a more qualified practitioner, but are unable to receive additional care due to financial difficulty or travel barriers [9].For many patients, it may be intimidating to travel to a larger city to obtain healthcare.For others such as the poor or elderly, transportation to a larger hospital or care facility may present an obstacle too daunting to overcome [2].The ethical challenge for nurses then becomes providing the best possible care to patients even with a limited amount of resources.Clinical competence is challenging in any field of nursing; however, it becomes especially difficult for rural health nurses.Financial constraints often limit the ability of nurses to travel for continuing education because the institution they work for cannot afford to pay for educational opportunities.In fact, it is often unrealistic to allow nurses to take time off work for educational conferences when they may be the only healthcare provider for the community [9].It is very important that rural health nurses be given the opportunity to advance their education and improve their professional competency [10].Rural health nurses must find a balance between practice patient demands and scarce resources [5].Recognizing professional limits and remaining within the competency of a nurse's scope of practice will help avoid situations that cause ethical conflicts for rural health nurses [8].
A second common theme identified in the review of literature is the experience of professional isolation [8,9].Historically, there has been a shortage of healthcare providers living and practicing in rural settings.Within the healthcare workforce, providers are taught the principle of professional collaboration.This is difficulty for nurses to achieve when they may be the only provider working in the rural community.Rural health nurses are expected to practice independently since other health care professionals may either be limited or unavailable [5].This lack of professional support can lead nurses to make the unethical decision to provide care beyond their scope of practice.Furthermore, nurses who practice alone often feel obligated to continue to care for patients even when they are tired or overworked.When this occurs, nurses are more likely to risk burnout and endanger the health and safety of their patients [8].Rural health nurses must be prepared to set professional limits to maintain ethical standards of practice and schedule time off to avoid becoming overwhelmed at work.
The third theme addressed is the presence of dual patient-provider relationships and their impact on professional boundary violations.Nurses who work in rural communities find themselves in a very visible role which can make it difficult to maintain separation between personal and professional life [4].Nurses can find themselves in situations where being a healthcare provider overlaps with friendships created within the community.In cases where nurse-client relationships last for a prolonged period, providing objectivity during health encounters is impaired.This can lead to unacceptable disclosure of personal information and a violation of the ethical standards of practice.When nurses interact with patients in social settings, privacy and anonymity is disrupted.This can result in ethical situations which cause role strain for nurses related to inability to remain nonjudgmental [9].Personal relationships with patients can cause an additional barrier in the delivery of healthcare when nurses struggle to keep their personal life private and protect the confidentiality of their patients [7].Practicing open communication will be a helpful for nurses because it clearly articulates the need to set boundaries with patients.Limiting the exchange of personal information is in the best interest for rural health nurses because it will help maintain a therapeutic patient relationship while avoiding the risk of unethical encounters [4].As in our case scenario (Table 2) what a nurse shall do when leaving in a small community and by knowing everybody, remains a challenge.
One more challenge is represented by communicating with others and by searching for help when is necessary by leaving in a "state" of isolation from other health care providers.Telemedicine has been applied to help

S. No Nurse code of ethics by Ana
1 The nurse will practice with compassion and respect the dignity, worth and unique attributes of every person.

2
The nurse's primary commitment is to the patient, whether an individual, group, community or population 3 The nurse promotes advocates and protects the rights, health and safety of the patient.

4
The nurse has authority, accountability and responsibility for nursing practice; makes decisions; takes action consistent with the obligation to promote health and provide optimal care.

5
The nurse owes the same duties to self as to others including the responsibility to promote health and safety, maintain competence and continue professional growth. 6 The nurse maintains and improves the ethical environment of the work setting that are conducive to safe, quality healthcare.

7
The nurse in all roles and settings advances the profession through research and scholarly inquiry, professional standard development and generation of nursing policy. 8 The nurse collaborates with other health professionals to protect human rights and reduce health disparities.

9
The profession of nursing must maintain integrity and integrate principles of social justice into nursing and health policy.Open Access 3 for future generations of nurses a rural health rotation within the nursing curriculum in order to better prepare nurses for working in this type of community.
The second recommendation will be to a medicine/nursing web system which will connect different nurses in a rural area among each other and to the major health system.hospital without specialist, countries without doctors.Critical Care, burn, pulmonary etc consults have been using around the country thanks to telemedicine in area where there is a lack of providers or of coverage [11].
Telemedicine is often use within the same system in health care to provide real time medicine off the campus.When I was at Texas tech we provide burn consult to other campus, the patient was place in the room and we could observe the burn and make recommendation.
In a similar fashion group of critical care doctors are providing consultation 24 hours a day to hospital in New York or in Florida by telemedicine [12].Therefore, we think that telemedicine can also use to help the nurse in rural area since they are isolated, to decrease the isolation and bring support and different competency on the table.That can be done by a physician but also by another nurse.We actually envy a telenursing as well where nurse can communicate and share their experience in different rural area, since they might have similar cases and from rural area to major medical center as well.

Conclusion
Rural health nursing presents both rewards and challenges to providers who choose to pursue a career in these communities.Nurses sometimes feel burdened by the constraints of scarce resources, lack of privacy and professional isolation.If not managed effectively, these challenges can create ethical conflicts for nurses.The first recommendation is to provide

S. No
Case scenario 1 Mr. W is a 68 year old terminal cancer patient who is receiving palliative care.He is in extreme pain, has lost ability to independently perform activities of daily living.The palliative care he is receiving is not able to relieve suffering due to extreme pain.He has voiced his choice to die a dignified death.He is of sound mental capacity.The amount of sedation he needs to minimize pain will keep him unconscious; therefore, will be requiring a feeding tube to meet his nutritional needs.He prefers to withhold treatment and allow himself to die.

2
Is it right to respect his autonomy and let him die? 3 What is in the best interest of the patient: • Preserving life?
• Alleviating pain and suffering?
n H U B f o r S c i e n t i f i c R e s e a r c h Citation: EE, Beltran CC (2017) Ethical Nursing Conflicts in Rural Health.J Epidemiol Public Health Rev 2(1): doi http://dx.doi.org/10.16966/2471-8211.137

Table 2 :
Case scenario