Background: Twenty percent of Americans live in rural areas where most of their healthcare is provided in Critical Access Hospitals (CAHs). It is unknown how frequently obstacle and helpful behavior items occur in End-of-Life (EOL) care in CAHs. Objectives: To determine the frequency of occurrence scores of obstacle and helpful behavior items in providing EOL care in CAHs. To also determine which obstacles and helpful behaviors have the greatest or least impact on EOL care based on the magnitude scores. Methods: A questionnaire was sent to nurses working in 39 CAHs in the United States. Nurse participants were asked to rate obstacle and helpful behavior items by size and frequency of occurrence. Data were analyzed to quantify the impact of obstacle and helpful behavior items on EOL care in CAHs by multiplying the mean size by the mean frequency of items to determine mean magnitude scores. Results: Items with the highest and lowest frequency were determined. Additionally, obstacle and helpful behavior item magnitude scores were calculated. Seven of the top ten obstacles were related to patients' families. Seven of the top ten helpful behaviors involved nurses ensuring families had positive experiences. Discussion: CAH nurses perceived issues around patient family members as significant obstacles to EOL care. Nurses work to ensure that families have positive experiences. Visiting hour issues seemed to be irrelevant. The use of technology, such as telehealth, seemed to provide little benefit in EOL care in CAHs.

Background: The Critical Access Hospitals (CAHs) system was developed to bring health care to rural populations. Although CAHs lack equipment and resources, CAH nurses still provide end-of-life (EOL) care to critically-ill and dying patients. Objectives: To determine the largest and smallest ranked obstacles and helpful behaviors to providing EOL care to rural patients as perceived by CAH nurses. Also, to determine how CAH nurses' perceptions of obstacles and helpful behaviors to providing EOL care compare to that of their urban counterparts. Methods: A cross-sectional, nationally representative sample of nurses working in 39 CAHs were sent a questionnaire. Nurse participants were asked to rate obstacle and helpful behavior item sizes to providing EOL care to critically-ill patients. Current data were analyzed and compared with previously collected data obtained from urban-working critical care nurses. Results: Seven of the top 10 largest obstacle items were related directly to family behaviors and attitudes such as families not understanding what lifesaving measures entail and intra-family disagreements about life support. Largest helpful behavior items ranked in the top 10 included interventions which the nurse controls and items that impacted nurses having adequate time to deliver EOL care. The majority of the top 10 largest obstacle and helpful behavior items from the 2015 study, as ranked by urban critical care nurses, remained in the top 10 for the current study. Obstacle and helpful behavior items unique to CAHs such as a lack of resources and the nurse knowing the patient or patient's family fell below the top 10 largest items in ranking. Conclusion: As perceived by nurse participants, obstacles and helpful behaviors to providing EOL care remain similar despite location (rural versus urban). CAH nurses are accustomed to working without typical resources found in urban hospitals and therefore did not perceive resource deficits to be among the largest-ranked obstacles to providing EOL care. Family behaviors and attitudes remain the most dominant obstacle noted by nurses.

Access to health care in rural communities is challenged by workforce shortages. Nurse practitioners (NPs) have been filling the gap created by physician migration into specialty areas. Flex hospital legislation allows critical access hospitals (CAHs) to staff the emergency department with NPs or physician assistants without on-site physicians. NP education often lacks emergency and trauma curriculum, resulting in gaps in education and practice expectations and leading to significant role transition stress and turnover. The purpose of this project was to construct an evidence-based transition-to-practice residency program to support NPs providing emergency department care in the CAH. Theoretical frameworks used to guide the project include rural health theory, novice to expert, and from limbo to legitimacy frameworks. Global outcomes include increased quality of care, patient safety, NP job satisfaction, and decreased turnover. The quality improvement initiative engaged an interprofessional team of institutional and community stakeholders (n = 10) to develop primary products including the residency program, curriculum modules, and the secondary products necessary to implement and evaluate the project. Implementation will consist of a pilot followed by expansion throughout the rural health network. Evaluation will involve the CAH dashboard to monitor patient outcomes, Misener NP job satisfaction scale, and employee turnover rates. The project expands understanding of the on-boarding needs of rural NPs. The results of this project will serve as a guide to publish outcome data and collaborate with higher education to develop programs to award academic credit for paid clinical experiences leading to academic degrees.

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