Public health nurses in rural / frontier one-nurse offices

Introduction: Public health nursing is the foundation of the United States’ (US) public health system, particularly in rural and remote areas. Recent increasing interest in public health in the USA has highlighted that there is limited information available about public health nursing in the most isolated areas, particularly in the US. The purposes of this study were to: (1) describe the characteristics, competency levels, and practice patterns of public health nurses (PHNs) working in remote one-nurse offices; and (2) compare PHNs working in one-nurse offices with nurses working in multi-nurse offices in Idaho, in relation to their demographic characteristics, practice patterns and competency levels. Methods: Using a cross-sectional descriptive design, a statewide sample of 124 PHNs in Idaho, including 15 working in onenurse satellite offices, were assessed in relation to their demographic characteristics, experience, educational background, job satisfaction, practice characteristics, and competency levels in March to May 2007. Results: The solo (nurses working in one-nurse offices) PHNs were based in 15 different counties, 10 frontier (population density of less than 7 persons/1.6 km 2 ; 7 persons/mile 2 ) and 5 rural. The counties ranged in population from 2781 to 28 114 (mean = 11 013), with population densities ranging from 0.9 to 29.4 persons/1.6 km (mean = 8.6; 0.9 to 29.4 persons/mile). The distance from their offices to the district main office ranged from 25.8 to 241.4 km (mean = 104 km; 16 to 150 miles, mean = 64.6 miles). All the solo PHNs were Caucasian females, with a mean age of 46.9 years and a mean of 22.5 years’ nursing experience. Educationally, 7 (47%) held a bachelor degree in nursing, 6 (40%) had associates degrees, 1 (7%) had a diploma in nursing, and 1 (7%) was a licensed practical nurse (LPN). These solo PHNs provided a wide array of services with support from other nurses in the district, including epidemiology, family planning/sexually transmitted disease clinics, immunization clinics, communicable disease surveillance, and school nursing. They expressed strong job satisfaction, citing the benefits of autonomy, variety, and close


Introduction
Public health nurses (PHNs) represent the foundation of the US public health system, particularly in predominantly rural and remote areas 1 .Nurses comprise 25% of the professional public health workforce in the USA 2,3 .Public health nurses focus on assessing community health, assuring access to care, developing policies that promote population health, advocating for public health policies, communicating with vulnerable populations, and fostering community resiliency 4 .Since the 1990s, public health systems nationally have moved away from providing direct care to individuals, to a renewed focus on population health.Recently, increasing attention has been paid to strengthening the national public health infrastructure and workforce in response to emergency preparedness concerns and impending workforce shortages 5 .Concomitantly, issues regarding PHNs' scope of practice and competencies have been raised [6][7][8] .

Rural public health challenges
Rural public health has also received increasing attention in the past decade.According to a National Association of County and City Health Officials' 1999 survey, 65% of all local health departments in the USA serve populations of less than 25 000 people 9 .High priority services provided by these rural public health agencies include environmental health, child health, and communicable disease control, particularly immunizations for adults and children 10 .In comparison with urban health departments, rural health departments tend to provide more personal health services, such as family planning and maternal/child care, laboratory services, community assessments, and community outreach/education, in spite of operating with lower funding levels, less access to grant funding, and geographic and transportation challenges 10 .In relation to the core public health functions, Suen and Magruder's research indicated that rural public health agencies had the lowest mean score on core function capacity, due to inadequate funding levels, planning capacity, and public health infrastructure 11 .Challenges rural public health agencies face include 'attracting a skilled workforce, maintaining strong leadership to advocate for and lead a prevention agenda, and ensuring population health activities' p.186 12 .In 2004, Bridging the Health Divide: The Rural Public Health Research Agenda identified the need for research in the areas of rural public health infrastructure, workforce development and competency enhancement, rural health disparities, access to care/safety net support, rural public health preparedness, and environmental health issues 13 .
Internationally, rural and remote public health has been addressed historically and currently in greater depth outside the USA.From a Canadian perspective, Bavington notes that rural and remote public health professionals often function as overworked generalists with long-distance supervision, mentoring, and consultation 14 .He also notes, however, that professional isolation can result in greater innovation and independence.The other international leader in rural and remote public health is Australia, with a rich history of 'bush nursing', which began in 1910 in Australia's most remote areas and continues today 15 .John Wakerman, the Director of the Australia's Centre for Remote Health, also speaks to the innovative nature of rural and remote public health and advocates for moving 'away from the deficit model of rural and remote health' (p.54) 16 .

Rural public health nursing
Several studies have demonstrated that US PHNs provide the majority of public health services, particularly in rural and remote areas.A major concern, however, is that in the USA most rural PHNs' highest level of nursing education is an associate degree, which typically does not include any curricular content in public health.In addition, the public health nursing workforce is aging and retiring at rapid rates, which creates serious workforce concerns, especially in rural and remote areas where recruitment and retention of well prepared nurses has been challenging historically 2,5 19,20 .In a study of the public health system in Idaho and Wyoming conducted in the period 1998-1999, Richardson et al. found that Idaho had 39 public health professionals per 100 000 people, over half of whom were nurses 21 .Consistent with national data, most of these nurses did not have formal preparation in public health.In a study of public health systems in Alaska, Montana, and Wyoming, Rosenblatt and Rosenblatt found that rural PHNs were more likely to work part-time but stayed in their positions longer than their urban counterparts 22 .

Rural public health nursing challenges
The Public health nurses working in the most isolated areas must provide a variety of services which requires a 'broad knowledge base, versatility, and the ability to improvise' (p.501 24 .In contrast with less remote settings, service delivery may be primarily home-based due to scarcity of health facilities and travel constraints 10,24 .Bushy and others note that the more remote the community, the greater the challenge in dealing with health care delivery and workforce issues, including recruitment and retention 25,26 .
International studies focusing on remote nursing practice in Australia and Canada provide important related insights.
Australian studies indicate that issues of high turnover, need for locum relief due to stress and fatigue, communication barriers and inadequate preparation and administrative support were consistent problems voiced by nurses serving remote Australian communities, often in one-nurse outposts [27][28][29]  thinking and adaptability to change skills, self-direction/selfmotivation, access to continuing education, and strong administrative support to address the chronic high turnover rates 34 .These findings support earlier research with Canadian outpost station nurses which documented challenges related to limited resources and travel requirements 35 .In both Canada and Australia, these isolated 'outpost' nurses 'do it all', providing primary care and crisis/emergency care along with public health services, which differs from US PHNs serving rural/remote communities who have a narrower scope of practice.

Public health nurse competency
In response to the increased attention on public health • analytic assessment skills

Comparison of solo public health nurses with public health nurses in multi-nurse offices
When compared with the PHNs working in multi-nurse offices, the solo PHNs were found to be quite similar, with no statistically significant differences, except in one competency area (Tables 1, 2).The solo PHNs were slightly younger than the non-solo PHNs.Experientially, the solo PHNs had more total nursing experience but fewer years experience in public health and a slightly higher mean number of years in their current position.In the non-solo sample, 56.4% held a BSN or higher, compared with 50% of the solo PHNs (who were RNs).There were no significant differences between the solo and non-solo PHNs in relation to demographic characteristics or competency ratings, with the exception of the competency area of 'community dimensions of practice skills'.In this area, the mean rating for solo PHNs was 3.9, compared with 3.2 for non-solo PHNs (t = 3.547, p = .002).In the multi-nurse offices, the nurses often reported specialized practices, focusing on a particular program, such as immunizations.In contrast, in the outlying one-nursing offices, the practice was described as more generalized with nurses working across programs in collaboration with other nurses in the district.

Discussion
This study represents the first description of PHNs serving in single-nurse offices in the USA.The solo PHNs in this study were predominantly middle-aged women with extensive experience in nursing and public health, and less than half of the sample held a bachelor or higher degree.These demographic characteristics are fairly consistent with previous studies in the USA, Australia and Canada.The solo nurses in the Canadian sample were slightly older than the Idaho sample and lived in somewhat smaller communities, with 75% living in communities of 2500 or fewer, and included 29.5% with a bachelor or higher degree (which was slightly higher than the total sample) 33 .The Idaho sample provided a wide range of public health services with support from other nurses in the district, and expressed strong job satisfaction, citing the benefits of autonomy, variety, and close community ties, however challenges related to isolation and communication with colleagues were noted.
These challenges are also consistent with those previously reported by Canadian and Australian nurses in remote practice.Their self-rated levels of competency were highest in the areas of communication, cultural competency, community dimensions of care, and leadership/systems thinking skills, and lowest in the areas of financial management, analytical assessment, policy development/program planning, and basic public health sciences skills.The solo nurses were very similar to their colleagues in multi-nurse offices demographically and in self-rated competency levels, except in the area of community dimension of practice skills, in which the solo PHNs were significantly higher than the non-solo PHNs.These findings suggest that US PHNs practicing in isolated one-nurse offices in rural and remote communities are comparable to PHNs working in less isolated settings; however, solo nurses self-report stronger community dimensions of practice skills.Their practice is more generalized than other PHNs and they express high levels of job satisfaction but some frustration with issues related to isolation and communication.This high level of job satisfaction along with the relatively low turnover rate contrasts with some previous reports from Australia and Canada among nurses in remote practice; however, this may be due to the degree of isolation and the strong connection to the community, along with differing demands and scopes of practice.The finding that the solo nurses were for the most part quite similar in demographic characteristics, education, experience and competency levels to PHNs working in multi-nurse offices, contradicts some possible biased perceptions that nurses serving the most isolated rural and frontier communities are less prepared than their more urban colleagues.Conversely, the results indicate that the solo nurses are highly autonomous with demanding, generalized practices.Based on these challenges, it could be argued that solo practice requires the highest level of PHN preparation and competency, which was not demonstrated in this study.
A critical finding was the fact that the solo PHNs self-rating of competency in relation to community dimensions of practice was significantly higher than the PHNs in multinurse offices.This finding is consistent with previous correlational analysis of competency levels and rurality, as measured by district population density, suggesting that PHNs serving rural and frontier communities feel as competent as nurses serving more urban areas and more competent specifically in the area of community dimensions of practice 44 .The fact that the solo nurses expressed significantly higher levels of competency in the domain of community dimensions of practice supports rural nursing theory and scholarship that has documented the strong community base of rural/frontier nursing in all areas of practice 45 .The generalized nature of solo public health nursing practice, in contrast to the more specialized focus of urban practice, may also contribute to the higher levels of self-reported competency among solo nurses in relation to community dimensions of practice skills.
The results also support the conceptual perspective of the influence of isolation on remote public health nursing

Limitations
The limitations of this study included the volunteer sample from only one state in the USA.Information regarding practice characteristics, attitudes and concerns among the solo nurses was somewhat limited, due to the brief nature of the structured interviews.Also, the rather simplistic nature in which competency was measured, along with the lack of reliability and validity data to support this measurement approach, represent limitations.This approach was necessitated based on the time demands of the larger study; however, in future research, more detailed assessment using all the Quad Council competency indicators could be used in order to measure competency in greater depth 40 .The fact that levels of competency were measured only by self-report represents an additional limitation.Validation of selfreported competency levels using supervisor and/or peer ratings would serve to strengthen future studies.

Conclusions and implications
infrastructure and quality in the USA, in 2004 the Office of Workforce Policy and Planning, Centers for Disease Control and Prevention (CDC) along with the Council on Linkages (COL) between Academia and Public Health Practice, developed a list of core competencies for all public health professions, including the following eight competency domains 39 :

The 15
PHNs who worked in one-nurse offices were based in 15 different counties (located in 6 of the 7 public health districts), 10 of which were frontier and 5 rural.The counties they served ranged in population (2005 estimates) from 2781 to 28 114 people (mean = 11 013), with land masses of 724.2 to 13 655.3km 2 (mean = 3753; 450 to 8485 miles 2 , mean = 2332), and population densities ranging from 0.9 to 29.4 persons per 1.6 km 2 (0.9 to 29.4 persons/mile 2 , mean = 8.6).The solo nurses' offices were located in communities ranging in size from 909 to 11 143 people (mean = 3471) (based on 2000 census figures).The distance from their offices to the district headquarters ranged from 25.8 to 241.4 km (mean = 104; 16 to 150 miles, mean = 64.6 miles).Demographically, the solo PHNs were all Caucasian females and their ages ranged from 31 to 64 years (mean = 46.9).They reported a mean of 7.7 years in their current position (range = 1-20 years), a mean of 8.6 years experience in public health (range = 1-20), and a mean of 22.5 years experience in nursing in general (range = 7-40 years).Educationally, 7 (47%) held a baccalaureate degree in nursing (BSN), 6 (40%) had associate degrees, 1 (7%) had a diploma in nursing, and 1 (7%) was an LPN.Two-thirds of the sample received their nursing education from in-state nursing programs.These demographic characteristics are fairly representative of the Idaho nurse population, except for the higher rate of baccalaureate prepared nurses among the solo PHN sample43  .Their self-rated levels of competency were strongest in the areas of communication (mean = 3.9), cultural competency (mean = 3.9), community dimensions of care skills (mean = 3.9), and leadership/systems thinking skills (mean = 3.6) and lowest in the areas of financial management (mean = 2.6), analytical assessment (mean = 2.6), policy development/program planning (mean = 2.8) and basic public health sciences skills (mean = 3.5).Their combined average level of competency ranged from 2.0 to 4.1 with a mean of 3.3.The solo PHNs reported providing a wide array of services with support from other nurses in the district, including epidemiology, family planning/STD clinics, immunization clinics, communicable disease surveillance, and school nursing.They expressed strong job satisfaction citing the benefits of autonomy, variety and close community ties.One frustration voiced by several solo PHNs related to problems in communication with the main district office and at times feeling 'out of the loop'.Communication with other nurses in the district was conducted mainly by email and phone.Most districts conducted monthly staff meetings at the main office which all nurses attend for training, coordination and networking.
practice.Maintaining strong communication networks and collegial support for solo PHNs are key strategies in

Further
research is indicated to compare these findings with other states, nationally, and internationally.In addition, further research is needed to more fully describe this unique subset of PHNs, particularly in terms of factors promoting recruitment and retention.Implications for practice and policy point to the need for ensuring the infrastructure to support PHNs in solo practice through strong support networks and adequate communication systems.Also, given the age and tenure of the solo nurses in this study, efforts to address future education and recruitment of PHNs to remote practice are indicated to ensure an adequate supply of nurses for the future in these vital roles and unique practice settings.These findings indicate that solo PHNs in Idaho provide essential services to remote communities, much like their colleagues in similar settings internationally.Lessons learned from this study include the need to continue to address resource and communication issues, including technology, to support PHNs in solo practice.The strong collaborative model in which Idaho's solo PHNs are supported by their nursing colleagues through the public health district structure may serve as a model for other states and nations to promote recruitment, retention and quality care.The fact that the PHNs in one-nurse offices were quite comparable to their colleagues in multi-nurse offices speaks to the commonality that an effective district structure with strong collegial and administrative support can produce.This cross-sectional descriptive study of PHNs in one-nurse versus multi-nurse offices in a predominantly rural state demonstrated the unique aspects of remote public health nursing practice as well as the commonalities with more urban settings.The strong job satisfaction and community orientation of solo PHNs, despite the geographic and professional isolation, affirms the positive nature of this unique practice setting.
. The landmark Canadian study The Nature of Nursing Practice in Rural and Remote Canada examined RN practice in rural and remote areas throughout Canada, in all clinical settings, including 412 nurses employed in community/public health agencies 30,31 .Results from interviews indicated the importance of local and long- 33stance collegial networks, accessible resources, and 'distance-proof, responsive management structure and processes' to address the nurses' feelings of being marginalized and 'being out of sight and out of mind' (p.46)32.Andrews et al's33analysis of the Canadian study data specifically focusing on nurses working alone in rural and remote settings (11.5% of the total sample) represents the most directly applicable comparable study to the present Idaho study.Their analysis included 81 nurses (19.9%) working in community health/public health agencies, which constituted the most common work setting for nurses working in one-nurse settings, followed by outpost nursing stations.They reported that work satisfaction, which was highest among diploma prepared nurses, was positively related to the ability to have face-to-face contact with colleagues, availability of equipment, and decision latitude.Barriers to continuing education and job-related psychological demands were negatively related to work satisfaction.Results specifically from 'outpost nurses' in Canada's remote northern communities, who provide care primarily to Aboriginal populations, indicated the importance of strong preparation, problem solving, critical . In addressing public health nursing practice in the most remote settings, professional and personal isolation may be particularly relevant challenges.Bushy stated (p.40) 36:Professional isolation is closely related to geographic isolation and can be perceived a positive, negative, or a combination of both.Many rural nurses enjoy the professional independence and creativity not usually found in larger practice settings.Others find that the responsibilities in a rural community health agency can be overwhelming.Often there is no immediately accessible professional network that can provide support and consultation on a matter of concern.Likewise, the lack of immediately available opportunities for establishing relationships with other professionals, or not having the 'central office' nearby, can reinforce feelings of isolation.Professional isolation requires an outstanding ability for a nurse to evaluate and prioritize needs and the types of services that can be provided to the local population.The lack of physical access to other providers, education, and technology can potentially cause considerable role strain.

Table 2
Idaho consists of 44 counties, two-thirds of which are classified as rural or frontier.The Idaho Office of Rural Health defines rural counties as those with no communities having more than 20 000 people, and frontier counties as those with population densities of less than 7 persons per 1.6 km 2 (7 persons/mile 2 ), which is consistent with national definitions.The US designation of 'frontier' is similar to the term 'remote' which is used more commonly internationally.
40e Quad Council of Public Health Nursing Organizations expanded on these competency domains in relation specifically to public health nursing practice40.The Quad Council competencies are also congruent with the American Nurses Association's (ANA) Public Health Nursing Scope and Standards of Practice 8 .Purpose Thus, the research-based knowledge related to the unique practice area of public health nursing in remote settings is extremely limited.The purposes of this study, therefore, were to: (i) describe the characteristics, competency levels, and practice patterns of PHNs working in remote one-nurse offices; and (ii) compare PHNs working in one-nurse offices Setting Idaho is a predominantly rural state in the Pacific Northwest region of the United States.With a population of 1.5 million, community settings with the job title 'public health nurse' or who identify themselves as PHNs.Nurses from the state office and each of the 7 public health districts in Idaho were included.The 2006 National Sample Survey of Registered Nurses estimated that there were approximately 70 PHNs in Idaho 42 .Based on this population estimate, we were confident that the majority of PHNs in Idaho were included in the study.). Th data were statistically analyzed using descriptive statistics, two-tailed Pearson correlations, ANOVAs, and independent t-tests, using a significance level of p <.05.