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Running Head: ETHICAL IMPLICATIONS OF RURAL NURSES’ WORK     EXAMINING HOW RURAL NURSES EXPERIENCE THEIR WORK AND THE ETHICAL IMPLICATIONS OF THOSE EXPERIENCES FOR RURAL NURSES IN BRITISH COLUMBIA   by    JENNIFER ARLENE SIEMENS B.Sc.N., British Columbia Institute of Technology, 2007    A SCHOLARLY PRACTICE ADVANCEMENT RESEARCH PROJECT SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF   MASTER OF SCIENCE IN NURSING   in    THE FACULTY OF GRADUATE AND POSTDOCTORAL STUDIES   (School of Nursing)   THE UNIVERSITY OF BRITISH COLUMBIA   Vancouver   April/2016     ©Jennifer Arlene Siemens, 2016 ETHICAL IMPLICATIONS OF RURAL NURSES’ WORK  ii	Table of Contents  Acknowledgements         v Dedication          vi  Chapter One: Background and Summary of the Significance of the Issue  1   Background         1    Ethical Implications       3   Application of an Ethics Lens     3  Summary of the Significance of the Issue in BC     4  Purpose and Scope of this SPAR      5  Methodology         6   Theoretical Framework      6    Critical inquiry.      6  Empirical Literature Review       7   PICO Framework and Research Question    7    Search terms.       8     Inclusion criteria.     8     Exclusion criteria.     9   Structure of the Literature Review     9    Chapter Two: Rural Health Care and Rural Nurses’ Work    10   Health Care in Rural Canada       10  Defining Rural and Rural Nursing      10   Defining Rural       11    Defining Rural Nursing      12   Rural Populations        13  Rural Nurses         14   The Nature of Rural Nurses’ Work     14  Chapter Three: Examining How Rural Nurses Experience Their Work  17     Article Selection        17   Qualitative Studies       18   Quantitative and Mixed Method Studies    18  Appraisal of the Evidence       19   Appraisal of Qualitative Evidence     19   Appraisal of Quantitative Evidence     19   Canadian Studies       20    National Canadian studies.     20    Provincial studies outside of BC.    21    Studies from BC.      21   International Studies       22    Scotland.       22 ETHICAL IMPLICATIONS OF RURAL NURSES’ WORK  iii	   The US.       22    Australia.        23  How Do Rural Nurses Experience Their Work?    23   Energizing Experiences      24    Rewarding.       24    Collaboration.       25    Lifestyle.       25     Challenge.       26   Distressing Experiences      26    Table 1.1: Rural Nurses Distressing Experiences  26    Scarcity of resources.      27    Accountability.      28    Great responsibility.       29    Lack of organizational support.    30    Nurses' values versus organizational values.   31   Relational Experiences      31   Dissimilar Findings       32    Rural versus urban.      32   Discussion        32    Themes        32     Competence.        32    Inseparable personal and professional role.   33     Trust and distrust.      33   Summary         34  Chapter Four: Implications of These Findings for Nurses Working in Rural BC 36   Pervasive Lack of Supports       36  Moral Distress  in Rural Nursing      37  Occupational Stressors or Moral Distress?     37   How Do Other Rural Health Care Professionals Fair?   38   Disjuncture Between Values       39  Enacting Moral Agency in Rural Nursing     39  Recommendations for Nursing Practice in BC    41   Practice Support       42    Rural Nurse Advocate position in BC.   42    Increase retention and recruitment.    43    Support an ethical practice environment.   44    Mutually decide the standard of acceptable care.  45    Support rural nurses’ work in BC.    46   Education        48   Policy         49   Current and Future Research      50  Conclusion         51  References          53 ETHICAL IMPLICATIONS OF RURAL NURSES’ WORK  iv	Appendices          60            A: Summary of the Energizing Experiences     60  B: Summary of the Distressing Experiences     62  C: Summary of the Relational Experiences     68  D: Summary of Key Points Used to Inform the RNCP   70                   ETHICAL IMPLICATIONS OF RURAL NURSES’ WORK  v	Acknowledgements  I would like to acknowledge the unconditional love and support of my family. Indeed, this is a masters that has been earned by my husband, Nathan Siemens, and my daughter, Isla Siemens. Nathan, thank you for being the super husband that you are and taking such great care of our family. Thank you for supporting me through this challenging endeavour. Your support and love is so important to me. To Isla, thank you for sharing your time with your mom with mom's graduate school work so that I could accomplish this endeavour. I know that this has not been easy for you to do. I love you to the moon and to planet nine and back.   Thank you to my extended family, my mom, Terry MacLeod, my father, Art MacLeod, Mommalee (Annalee Siemens), Lairdad (Laird Siemens) and Kelsey Spychka who loved and supported me and my young family throughout this process. Thank you for my friend and colleague, Jennifer Ham, for being my cheerleader and friend. I am so grateful for all of the friends and family who have patiently and lovingly supported me and my family through this process. I am grateful that there are too many to list here.  I am so grateful for the unwavering support of my supervisor and mentor, Dr. Paddy Rodney. The support that you provided me was beyond expectation. You are a great leader and teacher. Your accomplishments are inspiring and humbling. I am grateful for having the opportunity that I had to work with you. Thank you. I would also like to thank my committee member, Dr. Colleen Varcoe. Thank you for your support. Both of your work has informed my practice as a nurse and nurse educator. It was an honor to work with both of you.   Lastly, I am grateful for all of my nursing colleagues (MC) and friends who work in rural settings across BC. Thank you for all of your hard work.  ETHICAL IMPLICATIONS OF RURAL NURSES’ WORK  vi	Dedication      To My Love Nathan Siemens & My Sunshine Isla Siemens         ETHICAL IMPLICATIONS OF RURAL NURSES’ WORK  1	Chapter One: Background and Summary of the Significance of the Issue Background  Over the last two decades, there has been a growing body of evidence that recognizes the unique characteristics of rural nursing in Canada and the rest of the world (Buckley, 2015; MacLeod et al., 2004; MacKinnon, 2008; MacKinnon, 2010; Winters et al., 2006; Williams & Kulig, 2012). Indeed, the role of the rural nurse has been difficult to define, as it is variant in nature and complex (Jackman, Myrick & Yonge, 2010; Kulig et al., 2009; MacLeod et al., 2004). It is for this reason that rural nurses are identified as a generalist specialists or expert generalists (Bushy, 2006; Jackman, Myrick & Yonge, 2010; MacLeod et al., 2004; Williams & Kulig, 2012; Winters et al., 2006) within the literature. However, this distinction does not necessarily play out in the reality of rural nurses’ work, as rural nurses in British Columbia (BC), and other parts of the world, continue to work without explicit recognition of their specialized role related their unique knowledge base and skillset. For example, the Canadian Nurses Association (CNA) does not currently recognize rural nursing as a specialty and the current British Columbia Nurses’ Union (BCNU) collective agreement, which informs how nurses are employed in BC, is designated for all nurses despite geographic context (BCNU, 2012-2014).   Over the last three years as a graduate student at the University of British Columbia (BC), I have studied rural health care, rural nursing, rural health policy and the ethics of rural practice areas in BC. My research to date led me to want to understand how rural nurses experience their unique, integral and often unrecognized generalist specialist role, particularly in Canada and BC. As nurses are the most numerous health care providers in rural settings (MacLeod et al., 2004; Stewart et al., 2011; WHO 2010), I believe that further understanding how rural nurses experience their work could: inform effective interventions to address pervasive issues in rural ETHICAL IMPLICATIONS OF RURAL NURSES’ WORK  2	nursing such as the retention and recruitment of rural nurses; improve the quality of the health care services which rural nurses provide; identify the potentially distressing aspects of rural nurses’ work; and, lastly, profile energizing experiences related to rural nurses’ work.   As I will show in this paper, despite two decades of increasing evidence about rural health care and rural nurses' work, it appears there is still a lot of work left to do in order or such evidence to inform rural nurses' practice, education and policy, particularly in BC. This has not been due to a lack of effort on behalf of rural researchers. Many rural researchers have used their position to advocate for rural health care and the importance of rural nurses' work using action [rural] research1 in a variety of ways which includes, but are not limited to, describing the nature of rural nurses' practice (MacLeod et al., 2004), providing documentary analyses to support rural policy (Kulig et al., 2003; Kulig et al., 2013) and emancipatory research (MacLeod and Zimmer, 2005). However, notwithstanding the abundance of rural evidence available to inform rural health policies, nurses in rural settings continue to work under many of the same broad urban-based policies despite evidence that geographic context greatly impacts the nature of nurses’ work (Buckley, 2015; MacKinnon, 2012; MacLeod et al., 2004). It is evident that further work must be done to incorporate rural research evidence into areas such as practice support, education and policy. Therefore, my purpose in this Scholarly Practice Advancement Research Project (SPAR) is to explore empirical and theoretical literature about how rural nurses experience their work, and subsequently consider the ethical implications of the findings for rural nurses and rural health care delivery in BC.                                                   1 Action research "pursues outcomes and research outcomes simultaneously" (Dick, 1999 as cited in MacLeod and Zimmer, p. 69) Rethinking Emancipation and Empowerment in Action Research: Lessons from Small Rural Hospitals [in BC.]    ETHICAL IMPLICATIONS OF RURAL NURSES’ WORK  3	Ethical Implications  Ethical practice environments have a direct impact on the health and well being on those who provide and receive health care (CNA, 2008), which, in the case of this SPAR, are rural nurses and rural British Columbians. Consideration of ethical implications of how rural nurses experience their work acknowledges the impact of the "implicit and explicit values that drive health-care delivery and shape the workplaces in which care is delivered" (Rodney et al., 2006, p. 24). Such values impact nurses' work which requires, "the organizational and human support allocations necessary for [the provision of] safe, competent and ethical nursing care" (CNA, 2001 as cited in CNA, 2008, p. 27). Therefore, I will discuss the ethical implications of rural nurses' experiences in pursuit of an ethical workplace, as I recognize that there are often opportunities to improve the quality of health care practice environments. In order to accomplish this task, I have used the application of an ethics lens to identify the values which impact rural nurses' experiences. Application of an Ethics Lens  It has been suggested that disparities and inequities in health care are a result of incompatible values among various groups involved in the provision of health care (Rodney & Varcoe, 2012). Indeed, there is a growing need to consider the values of those who inform, provide, or access health care in order to understand how to improve how nurses experience their work, particularly in rural health care settings. The application of an ethics lens does just this. It recognizes the significant impact that values can have on all aspects of health care both those who are receiving the care and those who are providing the health care (Varcoe, Pauly, Laliberte, 2011).  ETHICAL IMPLICATIONS OF RURAL NURSES’ WORK  4	 Some findings suggest that rural nurses may experience distress due to a disjuncture between the values of the rural nurses and the values of the rural place of work (Bragg & Bonner 2014; Bragg & Bonner, 2015). The professional values of the rural nurses are the values of the profession of nursing which seeks to maintain the standard and quality of care as outlined by professional practice standards and professional codes of ethics. The application of an ethics lens considers how the values of rural nurses and others, such as the health care organization or rural community members, impact how rural nurses experience their work. Consideration of a possible disjuncture in values are important in order to understand how to better support rural nurses’ practice environments, which could a positive impact on the health and well being of rural British Columbians.  Summary of the Significance of the Issue in BC   Since the 1800s, nurses have been working in rural settings in BC (CRNBC, 2012) and Canada (MacKinnon, 2010). As previously noted, nurses are often the most numerous health care providers, or the only health care provider(s), in rural settings (MacLeod et al., 2004; WHO, 2010). In 2010, 11 percent of Registered Nurses (RNs) and Nurse Practitioners (28,799 nurses) were employed in rural Canadian health care settings (Pitblado et al., 2013). Yet rural nurses continue to be under-recognized, and possibly undervalued (Siemens, 2015). I noted in a recent policy analysis of the BC Ministry's of Health (MoH) Rural Health Services in BC: A Policy Framework to Provide a System of Quality Care (RHS) (BC MoH, 2015). In my analysis, which was performed via an ethics lens, I noted that a physician-led health care model was explicitly valued (Siemens, 2015) regardless of the reality that rural nurses provide the majority of rural health care services. For example, the BC MoH's (2015) first proposed action to address the health needs of rural British Columbians was to further increase physician incentive packages ETHICAL IMPLICATIONS OF RURAL NURSES’ WORK  5	(MoH, 2015), with no change to the limited incentives for rural nurses. The emphasis on physician-led services, as seen in the RHS (MoH, 2015), could demonstrate a lack of recognition and an undervaluing of rural nurses’ work in rural settings. The under-recognition of rural nurses in rural health policies such as the RHS (MoH, 2015) could have a significant impact on how rural nurses experience their work and, ultimately, the quality of care they are able to deliver to rural communities.  Purpose and Scope of this SPAR  The purpose of a SPAR under the UBC Master of Science in Nursing (MSN) Guidelines (2014) is to support 'real world' nursing practice in BC. As I have noted in my previous rural health policy analysis, Analysis of the Ministry of Health Policy Initiative, "Rural Health Services in BC: A Policy Framework to provide a System of Quality Care” (Siemens, 2015), there is a need to increase the valuing and recognition of rural nurses' work in BC. I believe that this SPAR addresses this need, as it explicitly recognizes rural nurses' unique and challenging work. Furthermore, this SPAR offers some recommendations on how to address the ethical implications of how rural nurses experience their work with interventions related to practice support, education, policy and future research for rural nurses working in BC.   In order to accomplish this task, the SPAR is organized into four chapters. In this chapter, I have articulated my purpose and scope and will subsequently describe the methodology for the SPAR. In Chapter Two, I will describe the unique nature of rural health care and rural nurses’ work. In Chapter Three, I will examine how rural nurses experience their work via an empirical literature review. Lastly, in Chapter Four, I will consider the implications of the findings of the literature review (via an ethics lens) related to practice support, education, policy and research. The scope of this SPAR will reflect the expectation that it will be completed within a single ETHICAL IMPLICATIONS OF RURAL NURSES’ WORK  6	semester (UBC, 2014) of graduate studies, which means that the literature review will not be as comprehensive as a masters thesis or doctoral dissertation but will contain enough references to answer the scholarly inquiry question. Methodology Theoretical Framework  Critical inquiry.  Rural nurses work within a geographic context known for its disparities and inequities in health care (MacKinnon, 2010; Romanow, 2002; Williams & Kulig, 2012) and in rural nursing practice (Buckley, 2015; Bushy, 2006; Lenthall et al., 2009; MacLeod et al., 2004). Such disparities and inequities related to the geographic location include, but are not limited to, decreased access to human, technological, geographic and organizational supports and resources (Bragg & Bonner, 2014; Buckley, 2015; Bushy, 2006; Grzybowski, Kornelsen & Cooper, 2007; Lenthall et al., 2009; MacKinnon, 2012; MacLeod et al., 2004). For the purpose of this paper, I have used theoretical framework of critical inquiry because it considers inequities related to the distribution of resources (Crotty, 1998). The distribution of resources is influenced by the values of those who decide how resources are distributed and, as my subsequent analyses show, as a result of inequities and disparities in resources, the health and well-being of rural Canadians and rural nurses are often negatively impacted. Inequities and disparities impact how rural nurses experience their work, therefore, the use of critical inquiry will allow for further understanding of values of various groups which impact rural nurses’ work.     ETHICAL IMPLICATIONS OF RURAL NURSES’ WORK  7	Empirical Literature Review  Nursing is a research based discipline which seeks to identify, describe, explore, explain, predict, and/or control various phenomena in order to ensure quality, evidence-informed nursing care (Polit & Beck, 2008, p. 17). In this case, through this SPAR, I sought to understand how rural nurses experience their work by conducting an empirical literature review informed by critical and ethical theoretical perspectives. An empirical literature review is a "critical summary of [objective empirical evidence] on a topic of interest, often prepared to put a research problem into context" (Polit & Beck, 2008, p. 732). Empirical evidence is "rooted in objective reality and gathered using one's senses as the basis for generating knowledge" (Polit & Beck, 2008, p. 726). In this paper, I was examining how rural nurses experience their work, therefore, I drew on the findings of many qualitative, quantitative and mixed method studies which examined how rural nurses, working in various areas of rural health care, experienced their work. In order to find appropriate literature for the empirical literature review, I used a PICO framework to formulate my scholarly inquiry question.  PICO Framework and Research Question  For the purpose of this empirical literature review, the PICO (population, intervention, comparison intervention, outcome) framework (Sackett, Richardson, Rosenberg, Haynes, 1997) was used to formulate a researchable question (Craig & Smyth, 2012), “How do rural nurses experience their work?”. Therefore, using the PICO framework: the population group was nurses in rural contexts (P); the intervention was rural nursing (I); the comparison group (C) was nurses working in urban contexts; and the outcome were rural nurses' experiences (O). Each article was reviewed in terms of the impact of rural nurses' experiences related to their work. Additionally, the rural practice area of each study sample was included (e.g., maternity, emergency, public ETHICAL IMPLICATIONS OF RURAL NURSES’ WORK  8	health etc.). Results were placed into a literature review table to compare and contrast the experiences of rural nurses from the articles. Summaries from the literature review table were created to summarize the energizing experiences (see Appendix A), the distressing experiences (see Appendix B) and the relational experiences (see Appendix C). I have explained how I have defined and identified these experiences in Chapter Three.  Search terms.  In the literature search, I looked at various nursing and health professional databases such as Medline, Pubmed, and Cumulative Index to Nursing and Allied Health Literature (CINAHL). Key search terms included nurs*, rural, rural nursing, experience, work, ethics, policy and rural policy, distress, stress and moral distress. Other terms that were considered include: positive, negative and impact. During the search for literature, I noted that many studies examined the phenomenon of 'job satisfaction' to examine factors which may impact issues such as rural nurse attrition, so the terms 'job satisfaction' as well as 'satisfaction' were included in the literature search. 	 Inclusion criteria.  Inclusion criteria allowed literature since 2002, as I have noted in previous research from other graduate courses that a lot of rural nursing research was done between 2002 and 2010. Literature within the last ten years was included from countries with similar health geography and rural nursing work to Canada (i.e, the United Kingdom, the United States of America (US) and Australia) has been reviewed. Peer reviewed literature that was published in English was included elected. Articles examining either rural or remote nurses were considered. Articles examining only rural nurses' work or comparing rural and urban nurses work were accepted. Lastly, quantitative, quantitative and mixed method studies were included. ETHICAL IMPLICATIONS OF RURAL NURSES’ WORK  9	 Exclusion criteria.  Content was excluded if the studies did not explicitly focus on rural nurses. Student nurses, nursing aides, health care aids and other allied health were not included, when explicitly identified, as the purpose of this SPAR is to consider implications for rural Registered Nurses’ work. Structure of the Literature Review  In the Chapter Three, the findings of the literature review are examined. The studies are discussed in the following order: Canada, provinces outside of BC, BC, followed by the studies from Scotland, Australia and the US. Next, the findings of all nineteen articles are used to answer the scholarly inquiry question, how do rural nurses experience their work, and the findings are summarized and separated into three categories: the energizing experiences, the distressing experiences and the relational experiences. Common themes from the findings are discussed. In Chapter Four, the critical and ethical implications of the findings of the empirical literature review for rural nurses in BC are discussed. Recommendations are made based upon the findings of the literature review with consideration of current policies in BC which inform rural nurses' work in BC. However, before discussing the findings of the empirical literature review, I will describe rural health care and the nature of rural nurses' work in Chapter Two.        ETHICAL IMPLICATIONS OF RURAL NURSES’ WORK  10	Chapter Two: Rural Health Care and Rural Nurses’ Work Health Care in Rural Canada  Little research had been done examining the nature of rural nursing in Canada until the landmark study, The Nature of Nursing Practice in Rural and Remote Canada, by MacLeod et al. (2004). This three-year national study found that rural nurses had a much more "complex and multi-faceted" role (p. 2) than had been previously known, despite rural nurses having worked in Canada for well over 100 years at the time of publication (MacKinnon, 2010). The findings of the study were published only two years after the Romanow Report (2002), Building Our Values: The Future of Health Care in Canada, which noted the complexities of rural health care in Canada, with an entire chapter (chapter seven) dedicated to discussing the inequities and disparities in rural Canadian health care and how they ought to be addressed. Indeed, since the early 2000s, much has been learned about the reality of rural health care and rural nursing in Canada as well as other parts of the world. What is less clear is how such evidence has been used to date. In this chapter, the findings of rural research will be used to explain the context of rural health care, rural populations, rural nurses and the nature of rural nurses work. This will include clearly defining the use of the term rural and rural nursing within the context of this SPAR. Defining Rural and Rural Nursing  Clearly defining the terms "rural" and "rural nursing" is important for the purpose of this SPAR. Furthermore, clearly defining rural is important more broadly as it informs the allocation of various health and human resources and can support the creation of effective rural health policy. Defining the term "rural" has been proven to be difficult, as there are over one hundred definitions of "rural" (WHO 2010; Williams & Kulig, 2012). This is not surprising, as no two ETHICAL IMPLICATIONS OF RURAL NURSES’ WORK  11	rural locations are alike, however, upon closer examination, many common characteristics are shared among rural nurses, rural health care and rural nurses’ work. Defining Rural  Indeed, the term "rural" is more of a continuum (Sibley & Weiner, 2011) than a succinctly defined or quantified point such as a census rural definition which is primarily based upon population density (Statistics Canada, 2007 as cited Williams & Kulig, 2012). However, in my previous policy analyses (Siemens, 2015), I have learned that census population data are commonly used by the BC MoH to inform the provision of health care services. I feel that this does not account for various geographic or economic characteristics which impact the health of those living in communities with larger populations. For example, defining rural solely based up on a population number, such as 10, 000 or less, without consideration of other community characteristics, such as access to specialized health services, is a problem in communities such as Williams Lake, BC. The hospital in Williams Lake services a local population of 18,475 British Columbians (Statistics Canada, 2011) which would be considered an urban center by simply defining rural based upon population census. However, similar to many rural communities, the residents needing specialized interventions, such as emergent cardiac catheterization to treat a cardiac event, would require transport, likely by air, to another geographic location, hours away from Williams Lake. Such an event requires the provision of timely intervention (Lambert et al., 2010) which is impeded by geographic barriers and can result in poorer outcomes for those living in communities such as Williams Lake. Indeed, such as a geographically isolated hospital which serves a population greater than 10,000 that does not provide many specialty interventions resulting in transferring patients to large centers which require overcoming geographic barriers or travelling a large distance. Therefore, for the purpose of this SPAR, the term rural will include ETHICAL IMPLICATIONS OF RURAL NURSES’ WORK  12	populations with similar geographic characteristics and a population size of >500 and <50,000 people (Kulig et al., 2008, p. 30). Within these parameters, nurses providing care within these rural contexts will be considered rural nurses. Defining Rural Nursing  A Canadian study by Kulig et al. (2008) sought to create a rurality index to guide the policy and practice support in rural health settings in Canada. As I am seeking to understand how rural nurses experience their work and the implications of their experiences to support practice, education, policy and future research in BC, I will draw on the findings of Kulig et al.’s (2008) study to define the term "rural nursing". In that study, 3412 rural nurses, from various rural settings and rural practice areas across Canada, were asked to define the term 'rural/remote'. The results of the study found that, "there were four identical overarching themes from the RN's definitions of rural and remote...: community characteristics, geographic location, health human and technical resources, and nursing practice characteristics" (p. 30). Lastly, the term rural considered the geographic location from health care services and/or to large health care facilities (i.e., more than one hour driving time) which provides specialty services (e.g., cardiology, neurology etc.) (Kulig et al., 2008 p. 30; WHO, 2010). In my research, I have found that distance from a larger health care facility can have a significant impact on the role and characteristics of rural nurses' work as rural nurses' portfolios often expand to accommodate the disparities (i.e., an uneven distribution of health care providers resulting in great differences in the provision of health care services in rural settings) of health care services and/or providers (e.g., porter, physician, lab technologist, housekeeping). Therefore, for the purpose of this SPAR, the term "rural nursing" will include nurses working within the aforementioned rural context which requires that nurses work with a larger role and scope of practice. the role and scope include the ETHICAL IMPLICATIONS OF RURAL NURSES’ WORK  13	duties of other allied health care providers and human support services. The distinct nature of rural nurses' work is described later in this chapter. In order to understand the reason for the role and scope of rural nurses, it is important to understand the unique characteristics of rural populations. Rural Populations  "Canada is comprised of 90% rural land mass" (Williams & Kulig, 2012, p. 1) which is home to between 19 and 30 percent of Canadians (Bollman & Clemenson, 2008 as cited in Williams & Kulig, 2012). As previously noted, the distinctive landscape of rural health care in Canada has many barriers, both human and systemic, which result in great disparities in health care delivery (Romanow, 2002). Rural Canadians have been found to have an increased prevalence of mortality and morbidity due to the geographic context where they live. Rural Canadians have an increased risk of accidents; increased risk of suicide; higher prevalence of smoking; decreased socio-economic status; increased chronicity; unpredictable access to various levels of health care services; and a shortage of "rural friendly" health initiatives (CIHI, 2006; Place, MacLeod, Johnston & Pitblado, 2014). Indeed, the geographic context in Canada may be an additional social determinant of health (Romanow, 2002), as findings suggest an increased mortality and morbidity rate for rural populations (CIHI, 2006; DesMeules, Pong, Lagace, Heng, Manuel, Pitblado et al., 2006; Mitura & Bollman, 2003; Nagarajan, 2004; Pampalon, Martinez & Hamel, 2006; Pong, DesMeules & Lagace, 2008). Such pervasive health disparities in rural Canada indicate a disparity in health that needs to be addressed. This is becoming increasingly important as the census report in Canada from 2006 revealed that the number of rural Canadian residents is increasing (Statistics Canada, 2009). Furthermore, rural populations are aging, potentially increasing the health care needs of rural communities as demographic findings ETHICAL IMPLICATIONS OF RURAL NURSES’ WORK  14	suggest that “by 2021 one in four seniors will live in a rural setting and 30% to 40% of rural and remote Canadians will be 65 or older” (Statistics Canada, 2006 as cited in Forbes & Edge, 2009), this does not pair well with a decline in rural nurses (Place, MacLeod, Johnston, & Pitblado, 2014). Particularly when the provision of rural health care in Canada ranges drastically from a single RN in a rural health care setting to several interdisciplinary health care members with a wide range of types of health care facilities and health care supplies (Kulig et al., 2008; MacLeod et al., 2004). This greatly impacts the nature of rural nurses' work. It is important to understand the common characteristics of rural nurses.  Rural Nurses 	 Some	of	the	common	characteristics	of	rural	nurses	include:	a	declining	number	of	rural	nurses;	larger	client	to	nurse	ratios	than	urban	nurses;	a	lower	level	of	education;	predominantly	female;	and	an	average	older	age	(Kulig	et	al.	2008;	MacLeod	et	al.,	2004;	Mill,	Field	&	Cant,	2011;	Pitblado	et	al,	2013;	Place,	MacLeod,	Johnston,	&	Pitblado,	2014).	Moreover,	some	findings	suggest,	an	increased	stated	intention	to	leave	their	place	of	work	(Stewart et al., 2011).	Additionally,	rural	nurses	in	Canada	often	have	more	than	one	employer	and	hold	fewer	full	time	positions	(Pitblado	et	al.,	2013;	Place,	MacLeod,	Johnston,	&	Pitblado,	2014).	In	addition	to	the	common	characteristics	of	rural	nurses,	the	nature	of	rural	nurses'	work	is	unique.		 The Nature of Rural Nurses' Work  Rural nurses work in geographic, professional and social isolation (Buckley, 2015; Lenthall et al., 2009; MacLeod et al., 2004; Zibrik, Macleod & Zimmer, 2010, p. 21). As such, rural nurses are the "first-line providers of health care with a large amount of responsibility" (Kulig et al., 2008, p. 31); responsibility which increases with the remoteness of the location of their work (MacLeod et al., 2004). Due to the nature of their work, rural nurses often accommodate for the lack, or limited supply of, health care providers through expanded roles ETHICAL IMPLICATIONS OF RURAL NURSES’ WORK  15	which require a "broad knowledge base" and the capacity to manage numerous clinical events with minimal supports and significant independence (Kulig et al., 2008 p. 31; MacLeod et al., 2004). For example, it is not unusual for a rural nurse to require the knowledge and skillset of a: surgical nurse, geriatric nurse, maternity nurse, emergency nurse, pediatric nurse and a medical nurse (O'Lynn et al., 2009; Winters et al., 2007). Rural nurses are expected to draw on this broad scope intuitively, with a level of expertise, regardless of the infrequency of specific tasks or interventions and frequently without the supports of time, rural informed policy and access to various supplies, supports or resources (Kulig et al., 2008; MacLeod et al., 2004; O'Lynn et al., 2009).   Rural nurses often provide emergent care with limited access to supplies as well as valuable resources such as time, fellow colleagues, rural nursing evidence (MacLeod et al., 2004; MacKinnon, 2008; Mills, Field & Cant, 2011; Winters et al., 2007), technology, equipment and medical transportation (Kulig et al., 2009, p. 30). Furthermore, in a rural Canadian health care setting, there is a high probability that the rural nurse will know the client, and the nurse will be directly and indirectly impacted by the outcome of intervention, as "personal and professional roles are inseparable" (Kulig et al., 2009; MacLeod et al., 2004, p. 3; Moules, MacLeod, Thirsk & Hanlon, 2010). Moreover, if a fellow member of the community requires emergent care, and the resources are available to perform the lifesaving intervention, the nurse must have a working knowledge of how to set up, support or implement the intervention regardless of the fact that they may have never performed this skill or have only performed the skill a few times in their career. The rural nurse is still expected to perform this skill with the same amount of expertise as their urban counterparts. If the intervention is successful, the community will likely celebrate their success; and if the intervention results in a less than favourable outcome, the community ETHICAL IMPLICATIONS OF RURAL NURSES’ WORK  16	will also know they participated, or provided their own, the intervention that resulted in a poor outcome for a member of their community (Buckley, 2015; MacKinnon, 2008; MacLeod et al., 2004).   Rural nurses are integral to rural health care in Canada. The scope and role of a rural nurses is quite broad, making the nature of rural nurses' work quite complex. So how do rural nurses experience their work and what are the ethical implications of their experiences? In the following chapter I will review the literature examining how rural nurses experience their work and I will subsequently consider the ethical implications of such findings for rural nurses in BC.                  ETHICAL IMPLICATIONS OF RURAL NURSES’ WORK  17	Chapter Three: Examining How Rural Nurses Experience Their Work  In this chapter, I will describe the findings of the empirical literature review used to answer the scholarly inquiry question, how do rural nurses experience their work and what are the ethical implications for their experiences? The following sections will describe the articles selected for review, followed by a summary of the research methods used in each study. Next, I will define energizing, distressing and relational experiences and summarize the evidence according to these categories. Finally, I will examine common themes. Article Selection  A total of nineteen articles were selected for the empirical literature review, which used qualitative, quantitative and mixed methods research designs, for the empirical literature review. Eleven studies were from Canada, five of the eleven studies were from rural BC, and eight studies were international. International articles included one from Scotland, two from Australia and five from the US. The search for literature describing how rural nurses experience their work revealed an abundance of action research describing rural nursing practice, however, limited studies specifically examined how rural nurses experience their work. As the purpose of this SPAR is to examine how rural nurses experience their work and the ethical implications of the findings for rural nurses’ working in BC., I focused on articles primarily from Canada and BC. In order to also provide an international perspective, articles from other countries (Scotland, Australia and the US) were included in the review. Articles were identified using the literature search methods described in Chapter One. Articles were collected until findings provided a wide scope of rural nurses’ experiences that spanned all provinces and territories in Canada from a variety of nursing practice settings in Canada and BC as well as internationally. Practice settings included novice and experienced rural nurses from acute care, community care, emergency, ETHICAL IMPLICATIONS OF RURAL NURSES’ WORK  18	maternity, public health, community palliative care, long term care, home care. Articles were selected until evidence in the studies appeared repetitive and common themes were noted. In the following section, I will describe the research methods for the studies categorized into Canadian and International categories.  Qualitative Studies  Fourteen of the nineteen articles selected used qualitative methods. As the research question was to examine how rural nurses experience their work, qualitative studies best addressed the research question as qualitative research has a "fundamental concern with meanings, experience and trying to understand how people make sense of their worlds" (Craig & Smyth, 2012, p. 105). The articles provided descriptive qualitative evidence which addressed the scholarly inquiry question. Quantitative and Mixed Method Studies   Four mixed method studies2  (Kulig et al., 2009; Molanari, Jaiswal & Hollinger-Forrest, 2011; Molinari & Monserud, 2008; Molinari & Monserud, 2009) and two quantitative studies (Baernholdt & Mark, 2009; Stewart et al., 2011) were included in the literature review. Six articles used mixed methods or quantitative methods to examine possible relationships among aspects of rural nursing such as: retention and recruitment (Baernholdt & Mark, 2009; Kulig et al., 2009; Stewart et al., 2011), education (Jaiswal & Hollinger-Forrest, 2011) and job satisfaction (Molinari & Monserud, 2009) using covariate or multifactor analyses.                                                     2Mixed methods uses elements of quantitative and qualitative approaches (Johnson et al., 2007 as cited in Craig & Smyth, 2012).  ETHICAL IMPLICATIONS OF RURAL NURSES’ WORK  19	Appraisal of the Evidence Appraisal of Qualitative Evidence  Each qualitative article was critically appraised and judged on how trustworthy the findings of the study were in order to understand if the study could accurately answer the question, how do rural nurses experience their work. According to Lincoln and Guba (as cited in Craig & Smyth, 2012), the trustworthiness of each study is assessed based upon four criteria: credibility, transferability, dependability, and confirmability (p. 119). This approach was used to judge the findings of each article. I believe that the transferability, dependability, and confirmability of the findings were enhanced due to the large scope of the articles selected. The broad scope provided international, national and provincial perspectives and revealed many common experiences among rural nurses. The credibility of the findings of each article were often reflected in the use of direct quotes from rural nurses who participated in each study. Initially, I assumed that studies with larger sample sizes increased the trustworthiness of the findings, however, Canadian health geographer Dummer (2008) states that larger national studies could allow for incorrect assumptions to be made about the needs of rural populations. Therefore, drawing from experiences from a local perspective (such as the five studies that examined rural health care in BC), in addition to several larger national studies, I believe, offered stronger evidence to inform rural nurses practice related to practice support, education, policy and future research. Appraisal of Quantitative Evidence  The instruments used in the mixed methods and quantitative studies used coefficient (Cronbach's) alphas to assess internal consistency of potential relationships among factors in each study. As such, research study reliabilities with a consistency less than 0.7 were not ETHICAL IMPLICATIONS OF RURAL NURSES’ WORK  20	included in the findings due to their reduced internal validity. As this was a literature review, a comprehensive critique of each study was not performed (Polit & Beck, 2012). Canadian Studies  National Canadian studies.  Three large national Canadian studies by MacLeod et al. (2004), Kulig et al., (2009) and Stewart et al. (2011) were selected for the literature review. The first article by MacLeod et al. (2004) was a landmark qualitative study that used four complementary data collection methods to understand The Nature of Nursing Practice in Rural and Remote Canada. The scope of the study drew from data from 3,933 rural and remote nurses from all provinces and territories in addition to 152 in-depth interviews. I judged that the methods and size of this study were robust and trustworthy, allowing for inferences to be drawn from the findings. The article by Kulig et al. (2009) used cross-sectional descriptive comparisons between community attachment, work setting and rural nurses' job satisfaction. The study used a stratified random sample of 3,331 rural RNs from a variety of work settings from western Canada. Kulig et al. used a cross-sectional survey to examine descriptive comparisons among the three variables using Analysis of Variance (ANOVA). The third article by Stewart et al. (2011) used a national, cross-sectional survey sent to a stratified random sample of rural RNs (95% CI) who were younger than 60 years of age to examine the predictors of rural nurses' intent to leave. The study used logistic regression to understand the relationship between behavioral intentions and turnover probability. The studies by Kulig et al. and Stewart et al. (2011) both used reliable instrument to collect data, including a questionnaire developed "based upon empirical and conceptual issues identified in previous research in Australia, Canada and the US" (Stewart et al., 2011, p. 105). Additionally, both studies used a modified version of Dillman's Tailored Design (2000) to ensure 'persistent follow-ETHICAL IMPLICATIONS OF RURAL NURSES’ WORK  21	up' with study participants. Overall, it was my assessment that the findings of the three studies were robust, allowing for inferences to be made regarding rural nurses experiences and rural nurses’ work.  Provincial studies outside of BC.  Two qualitative studies from Ontario were included (Hunsberg, Baumann, Blythe & Crea, 2009; Kaasalainen et al., 2014). The studies examined the experience of 44 rural nurses and 21 rural nurse managers (N = 64) employed in a variety rural hospitals (Hunsberg, Baumann, Blythe & Crea, 2009) and rural community nurses (N= 21) (Kaasalainen et al., 2014). Both studies used semi-structured interviews and performed thematic analyses. Findings of both studies were deemed credible as each provided rich description of their findings such as many direct quotes from participants.   Studies from BC.  Five qualitative studies were selected from BC (Buckley, 2015; Grzybowski, Kornelsen and Cooper, 2007; MacKinnon, 2008; MacKinnon, 2012; Moules, MacLeod, Thirsk and Hanlon, 2010) and one study examined rural nurses working in BC and Alberta (AB) (Zibrik, MacLeod & Zimmer, 2010). Rural nurses from acute care, emergency, public health, community and maternity practice areas were noted as participants. 138 rural nurses were explicitly noted as participants. Some studies did not provide specific numbers of rural nurse participants (Grzybowski, Kornelsen and Cooper, 2007; MacKinnon, 2012). Some studies indicated the general geographic location of the studies, which included participants from eastern BC (MacKinnon, 2008; MacKinnon, 2012), northern BC (Moules, MacLeod, Thirsk and Hanlon, 2010) and interior BC (Buckley, 2015).  Together these studies provided a comprehensive set of ETHICAL IMPLICATIONS OF RURAL NURSES’ WORK  22	findings describing how rural nurses experienced their work in many rural settings in BC, in a variety of health authorities. International Studies  Scotland.  Reid (2013) examined ten community rural nurses' experiences providing palliative care to children and young people in rural areas. The study was a qualitative phenomenological design. This study was selected to compare and contrast the findings of how rural community nurses experienced providing community palliative care in Canada (Kaasalainen et al., 2014).   The US.  Five articles from the US were reviewed. Three articles used mixed methods (Molinari & Monserud, 2005; Molinari & Monserud, 2008; Molinari, Jaiswal & Holliger-Forrest, 2011), one used quantitative (Baernholdt & Mark, 2009) and one used qualitative methods (Rosenthal, 2005). In 2008, Molinari and Monserud performed a qualitative analysis on two online surveys completed by 103 rural nurses who had worked a minimum of one year in rural hospitals in the Northwestern region to examine possible relationships between organizational characteristics and intention to leave. Additionally, Molinari and Monserud (2009) studied 104 rural nurses working in the Northwestern region using a mixed methods approach to examine relationships between cultural self-efficacy and job satisfaction. In 2011, Jaiswal and Holliger-Forrest elicited responses to qualitative and quantitative survey questions from 109 novice and expert rural nurses. The study used descriptive correlation design to examine rural nurses' lifestyle preferences and education perceptions. Lifestyle and education are frequently noted as factors that impact how rural nurses experience their work so this study was included in my review. ETHICAL IMPLICATIONS OF RURAL NURSES’ WORK  23	 Baernholdt and Mark (2009) performed a secondary analysis of a dataset from a random national study which sought to determine if there were differences in how nurses experienced their work related to rural and urban location. Finally, a qualitative study by Rosenthal (2005) examined "the lived experience of rural generalist nurses who work in an acute care hospital with less than twenty-five beds located in a mountain setting" (p. 37). The geographic setting of the study shared many common characteristics with many rural nursing practice settings in BC. Rosenthal interviewed eight rural nurses (seven RNs and one Licensed Practical Nurse) in a western rural mountain hospital. Data were analyzed and placed into four themes. The article described how rigor was achieved through using Sandelowski's (1986) four criteria to ensure truth value was established noting the four criteria: credibility, applicability, consistency and relationality to address confirmability.   Australia.  Two Australian studies by Bragg and Bonner (2014; 2015) were included in the review. Both studies used longitudinal findings collected from data from 2004 to 2009. The studies used qualitative, traditional grounded theory approaches. Both studies used the same dataset. The participants were twelve rural RNs (N=12) working in a variety of rural hospitals located in New South Wales, Australia. These articles were selected for review as they explicitly examined rural nurses' 'values' and discussed the potential impact of a possible disjuncture in values leading to rural nurses experiencing distress and eventually leading to their resignation (2015).  How Do Rural Nurses Experience Their Work?  I have summarized the findings from each article placed them into a table for review. Findings were separated into Canadian and International experiences and placed into three categories: energizing experiences (see Appendix A), distressing experiences (see Appendix B) ETHICAL IMPLICATIONS OF RURAL NURSES’ WORK  24	and relational experiences (see Appendix C) for review. My review revealed many shared experiences among rural nurses in all geographic locations and only a few differences. The findings of all nineteen articles have been summarized into three categories: energizing, distressing and relational experiences. The dissimilar findings are presented at the end of this review. Energizing Experiences  Although there were many more distressing experiences noted in the review, there were a number of energizing experiences (see Appendix A for a complete list). Experiences were deemed energizing when the experiences were explicitly regarded as positive (e.g., the use of the term "rewarding"). I noticed that there appeared to be a positive correlation between nurses' energizing experiences with an increase in the nurses' perceived self-efficacy. For example, nurses who felt more competent were more likely to perceive their experiences as energizing (MacKinnon, 2008) as long as they were able to provide care that adhered to their practice standards (MacKinnon, 2012). When these experiences were explicitly noted as positive, the findings were placed into the energizing.The following energizing experiences are divided into four themes: rewarding, collaboration, lifestyle and challenge.  Rewarding.  Many rural nurses found providing care rewarding (Reid, 2013) and experienced "many intangible rewards" (Hunsberger, Baumann, Blythe & Crea, 2009, p. 22) of nursing in a rural setting (Kaasalainen et al., 2014; Kulig et al., 2009; Molinari & Monserud, 2008; Reid, 2013; Rosenthal, 2005). Some of the experiences included the inseparable nature of their professional and personal identity as nurses reported enjoying the "visibility as a professional in the community as it the nurses felt trusted and respected" (Zibrik, MacLeod & Zimmer, 2010, p. 25). ETHICAL IMPLICATIONS OF RURAL NURSES’ WORK  25	Additionally, nurses appreciated the 'privilege' (Reid, 2013) of providing care to their fellow community members (MacKinnon, 2008). Lastly, it was noted that "caring for a known person had a profound impact on the nurse’s heart and soul" (Rosenthal, 2005, p. 44).  Collaboration.  Nurses appreciated and valued the effective teamwork and collaboration with members of the the health care team and the community, which was deemed a necessity for the success of their work (Bragg & Bonner, 2013; Bragg & Bonner, 2015; Buckley, 2015; Hunsberger, Baumann, Blythe & Crea, 2009; Kaasalainen, 2014; Molinari & Monserud, 2008; MacLeod et al., 2004; Moules, MacLeod, Thirsk & Hanlon, 2010; Zibrik, MacLeod & Zimmer, 2010). According to these studies, rural nurses required excellent interpersonal skills in order to establish and maintain effective and invaluable relationships with their colleagues and members of the community.   Lifestyle.  "Rural nursing is not a job; it is a lifestyle" (Kulig et al., 2009, p. 437). Many nurses enjoyed "the land, the solitude, the independence, the vigor, the harsh realities, the sublime beauty" (Kulig et al., 2009, p. 437) and the home life that the rural setting provided them (Kulig et al., 2009; Molinari, Jaiswal & Hollinger-Forrest, 2011; Molinari & Monserud, 2008). As one nurse noted, "I love life in the country" (Kulig et al., 2009, p. 436). There was a notion of "going home", "being home" and "returning home" (Kulig et al., p. 436). Nurses noted enjoying their rural surroundings recreationally and socially as energizing experiences (Kulig et al., 2009). Molinari & Monserud (2008) found that nurses who enjoyed their surroundings both socially and recreationally were likely to remain living and working in the community.  ETHICAL IMPLICATIONS OF RURAL NURSES’ WORK  26	 Challenge.  Many nurses "thrived on the challenge of the work" (Hunsberger, Baumann, Blythe & Crea, 2009, p. 20). As a result of the challenging work, nurses enjoyed their professional growth in rural practice environments (Buckley, 2015). Furthermore, nurses noted increased professional confidence due to the complexity and autonomy of the work (Hunsberger, Baumann, Blythe & Crea, 2009; Kulig et al., 2009; Molinari & Monserud, 2008).  Distressing Experiences  In general, there were many more distressing experiences than energizing or relational experiences (see Appendix B for a complete list). Distressing experiences depicted a negative experience. For example, I summarize some of the ways nurses described experiencing their work in Table 1.1.  Table 1.1: Rural Nurses’ Distressing Experiences "Scared" (Hunsberger, Baumann, Blythe & Crea, 2009; MacKinnon, 2008) "Exhausted" and “frustrated” (Hunsberger, Baumann, Blythe & Crea, 2009; Kulig et al., 2009) "Anxious" (Buckley, 2015; Gryzbowski, Kornelson & Cooper, 2007) "Distraught" (Buckley, 2015, p. 163) "Vulnerable" (Buckley, 2015) "Suffered moral pain" (Buckley, 2015) "Suffered moral distress" (Buckley, 2015; MacKinnon, 2008; Moules, MacLeod, Thirsk & Hanlon, 2010) "Distressed that their voices were unheard" (MacKinnon, 2008) "Concerns for liability" (MacKinnon, 2008) "Constrained by lack of resources" (Zibrik, MacLeod & Zimmer, 2010, p. 28) "Demeaned by larger centers" (Hunsberger, Baumann, Blythe & Crea, 2009; Zibrik, MacLeod & Zimmer, 2010) "Stressed" (Hunsberger, Baumann, Blythe & Crea, 2009) "Emotionally unprepared" (Reid, 2013) "Burnt out" (Hunsberger, Baumann, Blythe & Crea, 2009) "Discouraged" (Molinari & Monserud, 2009) "Undervalued" (Molinari & Monserud, 2008) "Compromised integrity" (Bragg & Bonner, 2014) "Shattered confidence " (Bragg & Bonner, 2014) "Physical health issues" (e.g.,palpitations, chest pain, hypertension) (Bragg & Bonner, 2014) "Devastated" (Bragg & Bonner, 2014; Bragg & Bonner, 2015) "Feeling of complete panic...and then we don't have the beds; we don't have the staff " (MacKinnon, 2012, p. 262) "Increased quantity of work while the quality has declined" (Kaasalainen et al., 2014) "Unsafe" (Buckley, 2015, p. 156)   ETHICAL IMPLICATIONS OF RURAL NURSES’ WORK  27	Common causes of distress were due to: scarcity of resources (e.g., human, technological, supplies and time); a strong sense of personal/professional accountability; and a lack of organizational support (e.g., conflict in values, poor management, lack of acknowledgement/compensation, lack of support, issues related to scheduling/staffing). Lastly, nurses felt distressed when interacting with larger centers. Scarcity of resources.  Researchers described nurses "providing nursing care with limited and, at times, unpredictable resources" (Buckley, 2015, p. 126). Lack of resources included, but were not limited to: lack of skilled colleagues (Hunsberger, Baumann, Blythe & Crea, 2009; MacKinnon, 2008; Molinari & Monserud, 2008); lack of adequate education and/or experience (Bragg & Bonner, 2014; Buckley, 2015; Gryzbowski, Kornelson & Cooper, 2007; Hunsberger, Baumann, Blythe & Crea, 2009; MacKinnon, 2008; Rosenthal, 2009); lack of authority (Buckley, 2015); lack of funding (Bragg & Bonner, 2014; MacKinnon, 2008); lack of physical supplies/equipment/compensation and technology (Bragg & Bonner, 2014; Kaasalainen et al., 2014; Molinari, Jaiswal & Hollinger-Forrest, 2011; Zibrik, MacLeod & Zimmer, 2010); lack of emergency preparedness (Molinari, Jaiswal & Hollinger-Forrest, 2011); and, finally, a lack of time for rest, for example, "working 36 hours straight, no sleep, no break, nothing" (MacLeod et al., 2004, p. 13). In one study, Buckley (2015) interpreted her observations of the rural nurses to reflect the "ethically challenging... day-to-day reality of managing high acuity patients under less than ideal working conditions with few resources" (p. 245). In addition to the stressors related to the nature of their work, I noted nurses often experienced distress related to a lack of resources for the clients for whom they cared (Moules, MacLeod, Thirsk & Hanlon, 2010). ETHICAL IMPLICATIONS OF RURAL NURSES’ WORK  28	 Due to the distress of bearing witness to extreme poverty and a scarcity of resources (such as a lack of basic supplies for clients), rural community and public health nurses in two studies from BC described how they often felt compelled to personally make up for the scarcity of resources (Kaasalanein et al., 2014; Moules, MacLeod, Thirsk & Hanlon, 2010) by providing items purchased out of pocket without expectation of compensation. For example, one nurse said "You know you're not supposed to be giving people things. That's really hard when they have nothing, no food in the cupboard... no diaper, no milk... and I did take her some meat once that I had in the freezer because she didn't have any. And I thought how do you walk away and think my kids are going to eat but hers aren't eating" (Moules, MacLeod, Thirsk & Hanlon, 2010, p. 332). The nurses often stretched their roles to try to make up for various disparities that they noted in their communities. However, it is unclear if the nurses were ethically challenged about providing care outside of their designated role.  Accountability.  Many of the nurses' narratives described a strong sense of professional accountability with statements such as, "we try to be all things to all people" (MacLeod et al., 2004, p.13); "we're it" (Buckley, 2015, p. 126); "you're it" (Rosenthal, 2005, p. 44); and "I find it difficult... here you kind of have to be everything to everybody, or try" (MacKinnon, 2008, p. 8). Indeed, the role of a rural nurse requires significant accountability and responsibility. Such stressors seemed to be compounded by the nature of the inseparable personal and professional role, as many nurses noted that the work never seemed to end (Buckley, 2015; Hunsberger, Baumann, Blythe & Crea, 2009; Rosenthal, 2005; Stewart et al., 2011; Zibrik, MacLeod & Zimmer, 2010). Due to their inseparable roles as nurse and community member, rural nurses noted a lack of anonymity (Rosenthal, 2005) within the communities that they lived in and at the same time rural ETHICAL IMPLICATIONS OF RURAL NURSES’ WORK  29	nurses struggled to maintain the confidentiality and privacy of their clients (Kaasalainen et al., 2014; Zibrik, MacLeod & Zimmer, 2010).   Great responsibility.  Nurses expressed the need to "be a good nurse" (Bragg & Bonner, 2014, p. 5), which meant "providing a high standard of care... treat patients with respect...provide comfort...and always be[ing] able to do the right thing" (Bragg & Bonner, 2014, p. 5). Nurses expressed having a great sense of responsibility to do their 'best', which often implied working outside of their scope to make up for disparities (Buckley, 2015; Zibrik, MacLeod & Zimmer, 2010), which may risk negative repercussions from their employer (Buckley, 2015, p. 201). Other nurses noted the stressors placed on them by the community to do their best, "if we didn't do what we had to do [the community chief/leaders] were going to ban us from the community" (MacLeod et al., 2004, p. 14). Furthermore, nurses placed additional pressure on themselves because they concluded that, "it's up to us" and "there is no one to fall back on" (Zibrik, MacLeod & Zimmer, 2010, p. 27); identifying themselves as "the most qualified in a situation" (Rosenthal, 2005, p. 44); and finding themselves in situations where they were the entire team—for example, "I am the trauma team" (Hunsberger, Baumann, Blythe & Crea, 2009, p. 20). MacKinnon (2012) found that "nurses felt responsible for their patients and neighbors, providing their services for free (p. 263).  Due to their strong sense of responsibility, nurses in one study spoke to management, seeking opportunities to practice their skills with no response, further compounding experiences of distress (MacKinnon, 2008, p. 10). Due to the nature of their expanded role and the nature of their work, rural nurses found themselves providing care in significant professional and geographic isolation, often resulting the distressing responsibility of complex decision making ETHICAL IMPLICATIONS OF RURAL NURSES’ WORK  30	(Buckley, 2015; Hunsberger, Baumann, Blythe & Crea, 2009; Stewart et al., 2011). These experiences were often exacerbated by a lack of structural and organizational support.  Lack of organizational support.  Many articles described distress due to a lack of organizational supports which included, but were not limited to, a lack of acknowledgement/compensation for rural nurses’ work (Molinari & Monserud, 2008; Molinari & Monserud, 2009); lack of knowledge of rural nurses' work (MacLeod et al., 2004); lack of supportive, effective rural policy (Buckley, 2015); and a lack of support related to staffing, education and scheduling (Kaasalainen et al., 2014; Zibrik, MacKinnon, 2012; MacLeod & Zimmer, 2010). Additionally, Bragg and Bonner (2014; 2015) postulated a possible disjuncture between the nurses' values and the organization's values. Many of the articles noted that the employers or urban health centers remained unaware of the complexity and nature of rural nurses’ work, which was previously identified in the landmark study by MacLeod et al. (2004). Rural nurses experienced significant distress as they were constrained from safeguarding their work by being declined adequate staffing levels which had been requested to ensure patient safety and/or uphold practice guidelines (MacKinnon, 2012). Nurses were told that the additional staffing was declined due to a lack of funding available, and staffing for hypothetical situations was too expensive (MacKinnon, 2012).  Despite years of evidence articulating the nature of rural nurses’ work, employers may still be unaware of all the complexities of their integral, expanded role, especially due to the increase of decentralization of care. Several articles noted that the decentralization of health care has created a greater distance between the managers of rural nurses and the rural nursing practice setting (Baernholdt & Mark, 2009; Bragg & Bonner, 2013; MacKinnon, 2012). Lastly, rural nurses experienced distress interacting with urban centers, stating that they felt demeaned or ETHICAL IMPLICATIONS OF RURAL NURSES’ WORK  31	disrespected by staff in larger centers who did not seem to be aware of their work (Buckley, 2015; MacKinnon, 2008; Zibrik, MacLeod, Zimmer, 2010).    Nurses' values versus organizational values.  Two Australian studies by Bragg & Bonner (2014; 2015) noted tensions among values which could lead to the resignation or attrition of rural nurses. One study by Bragg and Bonner (2015) suggested that when rural nurses' 'personal values' did not 'align' with the organization's values it would eventually led to their resignation. Of the twelve participants, three were noted to leave the profession altogether (only one over 50 years of age) and all twelve participants left rural work. It was unclear how the authors identified the participants’ values to conclude that they were 'personal'. My review of the Code of Ethics for Nurses in Australia (The Australian College of Nursing, 2008) noted many of the perceived 'personal values' aligned with the ethical values of the profession. This will be discussed further in ethical considerations. The Relational Experiences  I have used the term relational as it acknowledges that experiences are contextual and influenced by "the complex interplay of human life, the world and nursing practice" (Doane & Varcoe, 2015, p. 3). The term relational recognizes that each rural nurse's knowledge base, skillset and "particular way of being" (p. 3-4) impacted how they interpreted their experiences as energizing or distressing (e.g.,Hunsberger, Braumann, Blythe and Crea, 2009). My review of the relational experiences (see Appendix C for a complete list) noted that intrinsic properties (e.g., gender, age, experience, place of birth, level of education, professional/personal values, recreational/social activities etc.) (e.g.,Hunsberger, Braumann, Blythe and Crea, 2009) and extrinsic properties (e.g. ,geographic location, workplace organization and structure, leadership/management, health human resources, supplies, technology, vacancy level of the unit ETHICAL IMPLICATIONS OF RURAL NURSES’ WORK  32	etc.) greatly impacted how rural nurses experience their work (e.g.,MacLeod et al., 2004). For example, "intention to leave was significantly positively associated with perceived stress and level of education and negatively associated with years employed in one's primary agency" (Stewart et al., 2010, p. 108).  Dissimilar Findings  Rural versus urban.  Generally, findings were similar in the articles reviewed from Scotland, the US, Australia and Canada with a few exceptions. The dissimilar findings stood out as they were a result of studies with a different focus or purpose. For example, one study from Baernholdt and Mark (2009) suggested that geographic location did not significantly impact nursing turnover rates when compared to urban nursing practice areas. It is unclear if this was due to a difference in health care system structure. However, the same study noted that rural settings have lower vacancy rates (8.5% versus 12.7%) and that lower vacancy rates could increase turnover rate (Baernholdt, 2009), which raises questions about the turnover rate of rural nurses.  Discussion  Many themes were noted in the findings. For the purpose of this paper, I will focus on three themes: competence, the inseparable personal and professional role, and trust/distrust.  Themes  Competence.  Most of the participants were less formally educated than nurses found in urban centers. Regardless of their years of formal education, many rural nurses believed that rural nursing competence was only achieved through experience. Rosenthal (2005) referred to this method as "trial by fire" (p. 44). As nurses became more experienced in their role it appeared to increase ETHICAL IMPLICATIONS OF RURAL NURSES’ WORK  33	their energizing experiences. This meant that rural nurses felt more competent in their role and they felt better prepared to handle the complexity of the work, which resulted in perceiving their challenging work experiences as energizing instead of distressing. Moreover, rural nurses who were able to receive frequent education to maintain their competencies seemed to regard their work as more energizing than distressing. However, the inverse is also true. In the cases where nurses were unable to uphold practice standards (i.e., professional values) in the rural setting due to various constraints, rural nurses experienced significant distress (MacKinnon, 2012).   Inseparable personal and professional role.  The inseparable personal and professional role was noted by some nurses as energizing and others as distressing. The impact of the experiences seemed to be correlated with the outcomes of the clients. If a nurse provided care that resulted in a positive outcome, they were publicly praised and recognized (Kaasalainen et al., 2014). Conversely, if a nurse provided care that had a poor outcome, the nurse expressed fear of public shaming (Buckley, 2015) or fear of being excommunicated from the community (MacLeod et al., 2004). This theme has been frequently noted in the literature to date. As MacLeod et al. recommended in 2004, "the intertwining of [rural] nurses' everyday practice and their personal lives needs to be taken into account in developing policies and services" (p. i).  Trust and distrust.  Trust was highly valued by the nurses and was shared among colleagues and with members of the community. The nurses recognized trust as an absolute necessity to the provision of health care to the community. Trust between the health care leaders/managers and the rural nurses was also viewed as a necessity, as a lack of trust was noted to lead to distress and also attrition (Bragg & Bonner, 2015; Molinari & Monserud, 2009). Further distress was experience ETHICAL IMPLICATIONS OF RURAL NURSES’ WORK  34	when interacting with larger health urban centers, as nurses in two studies from BC reported feeling demeaned or disrespected by urban health care providers (Buckley, 2015; MacKinnon, 2008).  To understand this more, I searched for literature examining the concept of trust among urban and rural health care providers. I found a study from Alberta (Dis)-Trust in Transitioning Ventilator-Dependent Children from Hospital to Homecare (Manhas & Mitchell, 2015), which identified many intraprofessional challenges between urban and rural health care providers. The challenges included: a negative regard for rural health care providers; an explicit lack of trust; a lack of openness; and a lack of reliance between the rural and urban health care professionals (p. 922). The lack of trust appeared to arise from a lack of knowledge of the unique nature and scope of rural nursing. The lack of understanding appeared to result in the inequitable treatment of rural nurses by urban health care providers, potentially exacerbating rural nurses' experiences of distress.  Summary  In summary, in this chapter I have discussed the findings of an empirical literature view which used critical inquiry to identify a variety of inequities. Furthermore, I identified that many of the distressing experiences were a result of possible disjunctures between the values of health care organizations, rural nurses and, at times, members of the rural communities. It appears that the nature of rural nurses’ work provides many potentially energizing experiences. However, the findings made me wonder if the positive experiences related to the notably challenging and complex work are sustainable or if the work could inevitably lead to issues related to occupational distress, compassion fatigue, moral distress or burnout. Indeed, such challenges, and subsequent negative experiences, could negatively impact the health and well being of the ETHICAL IMPLICATIONS OF RURAL NURSES’ WORK  35	rural populations that the rural nurses serve. There was a significant amount of evidence denoting the distress which rural nurses often experience due to the nature of their work. One of the interesting findings of my literature review was the consideration of many intrinsic and extrinsic factors that may impact rural nurses' experiences or perception of their experiences. In Chapter Four, the ethical implications of nurses' experiences in rural settings will be discussed and recommendations based upon the evidence of this literature review will be considered for rural nurses in BC.   ETHICAL IMPLICATIONS OF RURAL NURSES’ WORK  36	Chapter Four: Implications of These Findings for Nurses Working in Rural BC  In this Chapter, I examine the predominant experiences of distress via an ethics lens. The discussion of the ethical implications of the findings will serve as a catalyst for the recommendations for rural nurses practice in BC. Such recommendations are related to practice support, education, policy and future research. Varcoe, Pauly, Webster and Storch (2012) recommend this approach of using moral tensions as a "springboard for moral action" (p. 52).  Pervasive Lack of Supports  As previously noted in Chapter Three, the findings of my empirical literature review revealed a significant lack of supports which included, but were not limited to, a lack of acknowledgement/compensation for rural nurses’ work (Molinari & Monserud, 2009; Molinari & Monserud, 2008); lack of knowledge of rural nurses' work (MacLeod et al., 2004); lack of supportive, effective rural policy (Buckley, 2015); and a lack of support related to staffing, education and scheduling (Kaasalainen et al., 2014; Zibrik, MacKinnon, 2012; MacLeod & Zimmer, 2010). Many of the disparities in supports were a result of larger systemic issues. For example, rural nurses working in public health and rural hospitals in BC requested opportunities to rehearse nursing skills to maintain safety and competency (MacKinnon, 2008). Unfortunately, the nurses' requests were denied, which further compounded their distress due to fear of unsafe practice within the context of an unsupportive organizational structure. Another example includes a study examining rural maternity nurses in BC (MacKinnon, 2012). The nurses experienced distress trying to maintain their professional standards by requesting additional staff to ensure the provision of safe maternity care. Their requests were denied by the organization due to a stated scarcity of funding which is reflective of larger systemic issue. Many of the experiences of distress were result of a disjuncture between nurses' professional values and ETHICAL IMPLICATIONS OF RURAL NURSES’ WORK  37	organizations' corporate 3values which was explicitly noted in several studies (e.g., Bragg & Bonner, 2015; Buckley, 2015; MacKinnon, 2012). These experiences can be understood as moral distress.  Moral Distress in Rural Nursing  For the purpose of this paper, moral distress is defined as, "the experience of being seriously compromised as a moral agent in practicing in accordance with accepted professional values and standards. It is a relational experience shaped by multiple contexts, including the socio-political and cultural context of the workplace environment" (Varcoe, Pauly, Webster & Storch, 2012, p. 59). The empirical literature review revealed that the most common experiences of thousands of rural nurses were implicit and explicit experiences of moral distress. For example, in three studies from BC, the experience of moral distress was explicitly noted (Buckley, 2015; MacKinnon, 2008; MacKinnon, 2012). Such distress has a negative impact on rural nurses as well as the populations which they serve. It is important to acknowledge the role that rural nurses can have in moral distress as nurses can act in ways that worsen their own, and others', moral distress (Rodney et al., 2013).  Occupational Stressors or Moral Distress?   All work, regardless of context, has some degree of stress (Varcoe, Pauly, Webster & Storch, 2012) which is not necessarily moral distress. Some rural researchers (Lenthall et al., 2011; Opie et al., 2010) have referred to many of the distinct stressors related to rural and remote nursing as occupational stressors. However, the rural context has its own unique set of ethical challenges (Nelson, Pomerantz, Howard and Bushy, 2007) due to the complex socio-political,                                                 3 Values which are based upon the political and economical values of the dominant group (Storch, 1996, p. 2 as cited in Rodney & Varcoe, 2012).  ETHICAL IMPLICATIONS OF RURAL NURSES’ WORK  38	geographic and cultural contexts of rural practice. The findings of the literature suggest that the rural practice setting may increase the risk and frequency of moral distress due to geographic context. How Do Other Rural Health Care Professionals Fare?  The evidence I have reviewed reveals a pattern of employment and departure which has persisted for at least the last two decades at provincial, national and international levels. This made me wonder if this was rural nursing specifically or more broadly also reflected in other health care professionals’ experiences in rural settings. An Australian study by Albion, Fogarty and Machin (2005) identified many occupational stressors related to the nature of rural nurses’ and other health sector professionals’ work and sought to identify if nurses perceived and/or experienced more distress than other rural health care professionals in rural settings. The study revealed that 432 rural nurses were noted to experience the highest levels of distress out of all of the health care professionals. Nurses experienced more distress related to their work. The factors related to their distress included challenges with recognition of their role, clarity of their role, their role as part of the health care team, and the workload demands of their role (p. 414). Additionally, nurses reported higher levels of individual distress, which was defined as, "negative personal feelings experiences at work" (p. 414) which included lowered individual morale, lack of leadership support and an incongruence between 'personal' and 'workplace' goals (p. 414). The article did not clearly define what personal goals were. Workplace goals were defined as "goals and values" (p. 414) leading to the impression that nurse experienced individual distress due to a disjuncture between their 'personal' and professional goals/values.    ETHICAL IMPLICATIONS OF RURAL NURSES’ WORK  39	Disjuncture Between Values  Many of the nurses' experiences of distress were a result of perceived or actual values conflicts between the nurses' values and the corporate values of health care organizations (Bragg & Bonner, 2014; Bragg & Bonner, 2015; MacKinnon, 2012). As I have indicated above, findings of several studies (e.g., Buckley, 2015; MacKinnon, 2008) explicitly described experiences of moral distress related to the nature of rural nurses' work. Rural nurses described the characteristics of moral distress when they were unable to meet guidelines and standards of care (MacKinnon, 2012, p. 262). Nurses noted in Kaasalain (2014), "there has been an increase in the quantity while the work quality has declined" (p. 6). In some cases, nurses' values were regarded as 'personal' (Bragg & Bonner, 2014; Bragg & Bonner, 2015), which I found concerning as the 'personal' values reflected the ethical values of the profession of nursing. Furthermore, there appeared to be a disjuncture between what is considered acceptable care between the rural nurses and the health care organizations. This was frequently demonstrated in the literature review in a manner that I interpreted as rural nurses attempting to enact their agency to address the disjuncture in values with the nurses’ personal provision of health care supplies or health services (MacKinnon, 2012; Moules, MacLeod, Thirsk & Hanlon, 2010). It left me wondering what is considered reasonable? And who gets to decide? How do nurses decipher between an act of agency and an act of insubordination? And, most importantly, how do decision makers make their decisions and how do their decisions impact the health and well being of rural populations? Enacting Moral Agency in Rural Nursing   Despite many challenges, the findings provided many examples of how rural nurses enacted their moral agency. Rodney et al. (2013) describe the concept of moral agency as: ETHICAL IMPLICATIONS OF RURAL NURSES’ WORK  40	rational and self-expressive choice, embodiment, identity, social and historical relational influences, and autonomous action within wider societal structures. That action requires recognition of and reflection on moral challenges, and is expressed at collective as well as individual levels (p. 163). As my literature review has indicated, the most common place where nurses enacted their agency was through the personal provision of supplies and/or services to compensate for disparities in resources. Nurses also tried to address various disparities and inequities by speaking to their managers (Bragg & Bonner, 2014; Bragg & Bonner, 2015; MacKinnon, 2008) or working beyond their scope of practice (Buckley, 2015). However, nurses reported that they also felt that their voices were not heard (Bragg & Buckley, 2014; Buckley, 2015; MacKinnon, 2012). As a result, nurses reported a sense of hopelessness (MacLeod & Zimmer, 2005) and left their positions (MacKinnon, 2012).  Some left the profession altogether, due to a perceived or actual disjuncture between the nurses' values and the organization's values (Bragg & Bonner, 2015). As Varcoe, Pauly, Webster and Storch (2012) recognize, "nurses often do act and pursue right courses of action but are frequently not heard or silenced and their actions are dismissed" (p. 58). However, it is important to note that any nurses working outside of their role and/or scope could lead to other ethical inconsistencies, further perpetuating an unethical practice environment (Rodney & Varcoe, 2012, p. 108).   When considering how rural nurses enacted their moral agency, it is important to revisit the characteristics of the rural nurses’ work that I described in Chapter Two as well as the findings of the literature review. Most rural nurses lacked the essential resource of time as their jobs were noted to 'never stop' (Buckley, 2015; Hunsberger, Baumann, Blythe & Crea, 2009). A lack of energy could also be a barrier to enacting moral agency due to persistently higher ETHICAL IMPLICATIONS OF RURAL NURSES’ WORK  41	workloads (Baernholdt & Mark, 2009; Kaalaslain et al., 2014), often leaving rural nurses exhausted (Kulig et al., 2009). Further, in the study Rethinking Emancipation and Empowerment in Action Research: Lessons from Small Rural Hospitals [in BC] by rural researchers MacLeod and Zimmer (2005), the researchers found that the rural nurses’ five separate rural hospitals faced additional unique barriers and risks to enacting their moral agency due the nature of their work (p. 77). Due to the pervasive lack of resources, and other distressing factors that are consistent with the nature of rural nurses’ work, rural nurses struggled to maintain their professional values within a context that is influenced by corporate values. As a result, rural nurses appear to suffer far more distressing experiences than energizing experiences which often led to burnout and/or attrition. There is a need to identify what is considered acceptable rural health care between organizations, rural nurses and the members of rural communities. Recommendations for Nursing Practice in BC  As previously noted in Chapter One, the purpose of a SPAR is to support 'real world' nursing practice in BC (UBC, 2014). In this final section, I will discuss the ethical implications of the literature review for rural nurses practicing in BC. The implications and recommendations are divided into four categories: practice support, education, policy and future research. The findings of the literature review, using critical inquiry and the application of an ethics lens, identified many disparities and inequities experienced by rural nurses as well as the rural populations which they serve. Many of the studies noted that rural nurses themselves and the members of the rural communities explicitly recognized rural nurses’ integral and important role. However, I also noted that rural nurses’ integral role was not consistently recognized or considered by those who are positioned higher in the organizational structures. This lack of explicit recognition increases the risk of undervaluing rural nurses, which could perpetuate many ETHICAL IMPLICATIONS OF RURAL NURSES’ WORK  42	of the pervasive issues in rural health care such as the attrition of rural nurses. Furthermore, consideration of the ethical implications of the findings revealed a possible disjuncture between the corporate values held by decision makers and health authorities and the professional values of the rural nurses who were seeking to provide, "safe, competent, compassionate and ethical care" (CNA, 2008, p.). Indeed, in many of the studies, rural nurses appeared to feel voiceless, replaceable and undervalued. Practice Support  Rural Nurse Advocate position in BC.  The empirical literature review noted that many health care providers, upper levels of health care organizations and decision makers are still unaware of the complex and integral role of rural nurses. This can be addressed through ensuring the physical location of managers and supervisors are in the units that they manage so that they can bear witness to the nature of the nurses’ work and the needs of the unit(s). MacKinnon (2008) found that the rural Public Health nurses' workloads were significantly higher than urban PHNs due to the nature of their work but this was not recognized by their provincial role description.  Upon examination of the organizational structure of nurses in BC, the Association of Registered Nurses of BC (ARNBC) appears to be best positioned to advocate for rural nurses at a policy level due to its its role in advocating for the profession of nursing in BC as well as its linkages with policymakers in BC. I believe that this would be best done through the creation of a Rural Nurse Advocate (RNA) position at the ARNBC. The RNA would require advanced knowledge in rural health policy and nursing ethics in order to articulate rural nursing practice issues effectively. In a similar vein, the ARNBC has created an Issues Report Form (ARNBC) where nurses from any area can submit an issue for review. Currently the form does not note if the issues are coming from a rural or urban ETHICAL IMPLICATIONS OF RURAL NURSES’ WORK  43	center4 The data could be used to inform the RNA of rural nursing issues throughout the province. Additionally, data could be collected with face-to-face visits to sites where the RNA, or nurses working in collaboration with the RNA, would connect with rural nurses in their place of work.  Such direct contact would be important, as the evidence reflects that many nurses do not have time or energy to perform additional duties such as paperwork even if it could result in improving their working conditions. Lastly, the RNA should work closely with the BCNU and the College of RNs in BC (CRNBC), as rural nurses’ issues must be addressed by correct courses of action. For example, workplace issues would be addressed by the BCNU; regulatory issues would be addressed by the CRNBC; advocacy, especially at a policy level, would be addressed by the ARNBC RNA.  Increase retention and recruitment.  There are many recommendations related to the recruitment and retention of rural nurses that have been made by rural researchers and health care researchers over the last two decades. Upon initial examination, it appears that the recommendations that researchers have been in a position to address have been the most commonly addressed recommendations. For example, there were many recommendations made in the early 2000s noting the need for more rural research. The abundance of rural research that was noted in the search for literature has given me the impression that this recommendation has been addressed. However, many of the recommendations of rural researchers and health care advocates, such the recommendations found in the Romanow Report (Romanow, 2002), have yet to reach fruition.  One of the most affordable ways to retain the nurses may be to acknowledge the nurses for their work and integral role in rural health care delivery. This would mean explicitly noting                                                 4 I have made this recommendation to the ARNBC. ETHICAL IMPLICATIONS OF RURAL NURSES’ WORK  44	them (with a similar frequency as rural physicians) in rural health care policy documents such as the Rural Health Services in BC: A Policy Framework to Provide a System of Quality Care (RHS) (BC MoH, 2015). Furthermore, in consideration of the rural nurses' incentives, a review of the incentives for rural nurses appears to be minimal and may require reconsideration. As previously noted, the the first recommendation to take action on in the RHS was to increase the incentives for physicians to entice them to work in rural settings. Yet in 2011, the qualifying conditions for the loan forgiveness program changed for nurses and family physicians working in underserved communities. Now, only nurses and family physicians who have started working in rural communities as of July 1, 2011 (Human Resources and Skills Development Canada, 2013) qualify for loan forgiveness. This has decreased the incentive for more senior nurses and physicians who started working in rural and remote communities in BC prior to July 1, 2011 to remain in the rural health care settings, resulting in a possible decrease in access to rural health care expertise. Lastly, in consideration of the findings of the review, I noted that nurses who were from the rural community where they worked, were less likely to express an intent to leave (Kulig et al., 2009 & Stewart et al., 2011). Therefore, consideration of incentives for rural residents to seek to become rural RNs could improve the retention of rural nurses in BC.   Support an ethical practice environment.  Rural nurses and health care organizations need to seek ways to foster moral communities. Moral communities can be defined as: a workplace where values are made clear and are shared, where these values direct ethical action and where individuals feel safe to be heard (adapted from Rodney & Street, 2004); and where coherence between publicly professed values and the lived reality is necessary for there to be a genuine moral community (Webster & Bayliss, 2000). (CNA, 2008, p. 27) ETHICAL IMPLICATIONS OF RURAL NURSES’ WORK  45	As I have argued in this paper, rural health care presents unique ethical challenges (Nelson, Pomerantz, Howard & Bushy, 2007) and there is a need to seek ways to foster a "morally habitable work environment that is supportive of and encourages discussion on ethical issues intentionally fosters a positive, reciprocal relationship between healthcare structures and moral agents [nurses]" (Musto, Rodney & Vanderheide, 2014, p. 7). This can be addressed through more integration of ethics into rural health care delivery through the use of strong leadership, supportive management, and the use of an RNA. There must also be opportunities to educate nurses about their role in contributing to an ethical environment (Musto, Rodney & Vanderheide, 2014). I was deeply concerned with a statement in one study where a senior nurses stated that, "new graduates are making their lives as important as their careers" (Hunsberger, Baumann, Blythe & Crea, 2009, p. 21), as such statements are divisive and do not foster a supportive, ethical practice environment. Furthermore, rural nurses can seek to protect against experiences of moral distress and compassion fatigue through supporting each other in activities to ensure self-care and fitness to practice (CRNBC, 2008), as well recognizing symptoms of distress and supporting each other in addressing stressors. Lastly, it is essential that rural nurses are valued for their expertise regardless of their level of formal education. This can be demonstrated through using senior nurses to formally mentor new nurses. Furthermore, it may be important to consider recognizing rural nursing as a specialty by the CNA with subsequent rural specialty certification.  Mutually decide the standard of acceptable care.   Rural Canadians currently suffer increased mortality and morbidity rates compared to their urban counterparts (Jackman, Myrick & Yonge, 2010; Romanow, 2002; Williams & Kulig, 2012); an increased turnover of rural nurses (Bragg & Bonner, 2015; Molinari & Monserud, ETHICAL IMPLICATIONS OF RURAL NURSES’ WORK  46	2008; Stewart et al., 2011); and findings that suggest that rural nurses may be a socially and politically marginalized group (MacLeod & Zimmer, 2005). Indeed, these findings cannot reflect acceptable standards for rural health care or rural nurses’ work. Explicitly identifying a mutually agreed upon standard of what is acceptable health care in rural settings could reduce the occurrence of such distress. The standard must be deemed acceptable by the organization and by those who provide and receive the care. The standards should address the unique needs of rural populations while providing a supportive health care structure for those who provide rural health care delivery. To be clear, this recommendation does not suggest a costly overhaul of rural health care delivery. Instead it suggests that the poorer health outcomes and disparities in rural health care, which were first described by Romanow in 2002, are addressed in a manner that also considers the evidence regarding the significant amount of distress which rural nurses may experience.   Support rural nurses’ work in BC.  In recognition of nature of rural nurses’ work and their experiences of their work, it is important to consider the supports they need. Many nurses spoke of how they volunteered their time, provided health services without payment or provided items to support the health of members of the community out of pocket. The nurses need to be recognized for their efforts to go above and beyond their paid work in the community to care for the members of their community. Leaders in health care ought to acknowledge the nurses, pay them for their work and acknowledge their acts of moral agency in addressing disparities in the communities where they work and live. In a similar vein, due to the never-ending nature of their work (Buckley, 2015), nurses must be provided adequate times of recuperation by approving their vacation requests without restricting their vacation time. Currently many Health Employers in BC restrict the ETHICAL IMPLICATIONS OF RURAL NURSES’ WORK  47	number of RNs to be on vacation per a 24-hour period in rural and urban practice settings in BC.  Such restrictions can impact rural nurse's necessary vacation time, which they are entitled to per their collective agreement (HEABC & BCNU, 2012-2014). Perhaps the BCNU could consider including language in the collective agreement to prevent restriction of vacation time that increases stress for the nurses and decreases periods of needed rest. The intended purpose of the vacation restriction appears to be an effort to reduce overtime (i.e., cost-saving measures) and issues related to safe staffing. However, it is important to consider the cost of replacing nurses who have become exhausted, burnt out or distressed due to a lack of opportunity to rest. O'Brian-Pallas, Duffield and Hayes estimated this cost to be approximately $21, 514 in 2006 (as cited in Bragg & Bonner, 2015, p. 369). Overall, it is important to consider how the collective agreement can impact nurses practicing in rural BC.  Additionally, it is important to consider the employment patterns in rural communities as such patterns should not be impacted by a collective agreement which seeks to achieve similar employment and staffing levels as urban areas. Many Canadian rural nurses noted a lack of casual nurses (MacKinnon, 2012) and the necessity of working part-time jobs (Hunsberger, Baumann, Blythe & Crea, 2009). However, the collective agreement maintains a policy that all casual Registered Nurses working in any area of BC must work a minimum of 225 hours annually (HEABC & BCNU, 2012-2014). This can be challenging for many reasons in rural BC and has also led to the dismissal of casual RNs working in rural communities, further shrinking the rural nursing casual pool. Moreover, the minimum of 225 hours prevents rural nurse educators from maintaining casual status as rural nurses. There is a need to consider utilizing the rural nurse educators in underserved communities in rural BC where they could provide valuable expertise and on-site training and support to nurses working in rural and remote communities. ETHICAL IMPLICATIONS OF RURAL NURSES’ WORK  48	Lastly and overall, my final recommendation would be for managers to consider the evidence of the nature of rural nurses’ work and to seek out ways to address their unique needs  Education  The topic of rural nurses' education in BC has been an identified need since the landmark study by MacLeod et al. in 2004. This theme was also noted throughout the literature review. Rural nurses experienced distress because of their lack of access to appropriate and effective education to ensure the maintaining of their own professional competencies. Therefore, rural researcher and nursing scholar Dr. MacLeod has created a Rural Nursing Certificate Program (RNCP) out of the University of Northern BC (UNBC). The curriculum for the RNCP was developed based upon the realities of rural nurses’ work (MacLeod, Lindsey, Ulrich, Fulton and John, 2008; see Appendix D for a summary of key points used to inform the development of the RNCP). Since the inception of the program, an assessment of the efficacy of the program was done by Place, MacLeod, John, Adamack and Lindsey (2011), which noted that rural nurses did benefit from additional educational opportunities.  However, rural nurses face many barriers to their education. It is evident that the delivery of rural nurses’ education needs to be built into their workload schedules. Rural nurses noted a struggle to find time to work on their education due to work obligations (Place, MacLeod, John, Adamack and Lindsey, 2011). I propose that rural nurses receive more paid education opportunities; opportunities which are incorporated into their work schedule to ensure the provision of safe and competent nursing care and to reduce the experiences of distress. It is important to note that a resultant reduction in stress reduces sick time and turnover (e.g., Molinari & Monserud, 2008) could make this a potentially feasible endeavor. There is also potential opportunity to seek funding support from the BCNU. Overall, this recommendation for ETHICAL IMPLICATIONS OF RURAL NURSES’ WORK  49	paid educational opportunities acknowledges the nature of rural nurses’ work, as nurses do not usually have time or energy outside of their busy schedules to seek out educational opportunities. Furthermore, the educational in-services could provide opportunities for nurses to discuss their needs and/or collaborate.  It is also important to consider the expertise of those rural nurses who often possesses less formal education but have an abundance of experiential learning--learning which is often underutilized to support their practice as well as the practice of nursing students. Nurses need "workplace supports for using their knowledge and incorporating it into the fabric of their practice" (MacLeod & Zimmer, 2005, p. 75). It may be necessary to consider the requirements for rural clinical nurse educators to teach nursing students. The most qualified rural nurses often do not have their nursing degree so they could be provided the opportunity to become qualified with a program that rewards their experience with credits earned. Lastly, nursing programs in BC need to find ways to teach nursing students about the unique nature of rural nurses’ work.  Policy  For the purpose of this section, the implications of the findings for policy will include two recommendations:  the need for rural health policy in BC and the need to use rural-proofing (DEFRA, 2002) methods to allow for better application of urban policies to rural settings in BC. Rural-proofing is defined as a process which considers the impact of urban-born policies on the well-being of rural populations, making policy adjustments as required to ensure that the needs of rural populations are addressed with equitable policy (DEFRA, 2002, p. 2). This recommendation has also been noted in Rural and Remote Nursing Practice: An Updated Documentary Analysis (Kulig, Kilpatrick, Moffitt & Zimmer, 2013). Rural-proofing may also be a better approach to the allocation of services and resources as it directly considers the needs of ETHICAL IMPLICATIONS OF RURAL NURSES’ WORK  50	rural populations. The process of rural proofing could be done with an interdisciplinary group of health care professionals, which would include a seat for the RNA.  The second approach to policy would be the creation of rural health policy for enactment in rural settings in BC. Such policy would explicitly and equitability acknowledge all rural health care providers in rural settings. This is an important initiative, as the RHS (MoH, 2015) did not explicitly acknowledge or consider rural nurses in many parts of their policy discussion paper. Additionally, the creation of rural policy should be informed by the evidence, drawing from the numerous rigorous Canadian studies. As I have previously noted in my analysis of the RHS (MoH, 2015), evidence from studies outside of Canada such as Australia can inform rural health policy in BC. It is important to acknowledge the significant amount of work that has been done to date by rural researchers. For example, a comprehensive documentary analyses of 159 Canadian policy documents in 2003 was completed by Canadian rural researchers Kulig, Thomlinson, Curran, Nahachewsky, MacLeod, Stewart and Pitblado and was followed by an updated analysis in 2013 (Kulig et al., 2013). Current and Future Research  Many of my recommendations made in this SPAR to address the unique nature of rural health care and rural nurses’ work are also noted in many studies that I reviewed during my time as a graduate student. Indeed, it is time to act on these recommendations, which are founded upon strong evidence. Given the strength of the research that already exists, I will focus only on two future research recommendations. First, there is a need to examine the concept of moral distress within the context of rural nursing in greater depth, particularly regarding the relationships among values which appear to increase the prevalence of moral distress. Secondly, one of the most important needs for future research, as recognized by MacLeod & Zimmer ETHICAL IMPLICATIONS OF RURAL NURSES’ WORK  51	(2005), is to continue to participate in action research to find ways to incorporate rural evidence into rural nurses’ practice. As MacLeod and Zimmer (2005) have noted, it is important to recognize that rural nurses are not in a position to emancipate themselves and they are relying on the actions of others, such as rural researchers, to advocate for their needs. Conclusion  In this paper, I examined the energizing, distressing and relational experiences related to rural nurses’ work. The empirical literature review suggests that rural nurses experience distress more frequently compared to the energizing or relational experiences. Through critical inquiry and the application of an ethics lens, many disparities and inequities were noted, often due to tensions between values of rural nurses, rural communities and rural health care organizations. As I have noted earlier, many of the findings of this review are not new. They have been articulated by many scholars, such as rural researcher experts Dr. J. Kulig, Dr. M. MacLeod and Dr. K. MacKinnon.  The purpose of this SPAR was to examine how rural nurses experienced their work and the ethical implications of the findings for rural nurses in BC. The SPAR has provided me with the opportunity to profile the experiences of thousands of rural nurses working in rural settings in BC, Canada, the US, Scotland and Australia. This graduate project allowed me to acknowledge the pervasive inequities and disparities experienced by rural nurses, rural populations and myself as a rural Canadian and as a rural nurse. I have done this because I am a nurse and, as a nurse, I am politically oriented toward a concern for social justice and, as such, I “endeavor to maintain awareness of aspects of social justice that affect health and well-being” (CNA, 2008, p. 2) of all population groups. In this case, those groups include rural nurse working in BC and rural British Columbians. These are the values of my profession.  ETHICAL IMPLICATIONS OF RURAL NURSES’ WORK  52	I would like to close using the voices of fellow rural nurses and their recommendations for improving rural health care in Canada: “value [rural and remote] nurses and involve them in the shaping of their practice and work environments. Too frequently, rural and remote front-line nurses feel that they are peripheral to the decision making that goes on about their work and work environments” (MacLeod, Kulig, Stewart & Pitblado, 2004, p. 18). With careful collaboration from all rural health care providers, rural nurses and rural British Columbians, there is opportunity for more ethical and equitable rural health care in BC.                  ETHICAL IMPLICATIONS OF RURAL NURSES’ WORK  53	References  Albion, M., Fogarty, G., & Machin, M. (2005). Benchmarking occupational stressors and strain levels for rural nurses and other health sector workers. Journal of Nursing Management, 13(5), 411-418. doi:10.1111/j.1365-2834.2005.00538.x  Australian College of Nursing. (2008). Code of Ethics for Nurses in Australia. Melbourne, Australia: Nursing and Midwifery Board of Australia. Baernholdt, M. & Mark, B. A. (2009). The nurse work environment, job satisfaction and turnover rates in rural and urban nursing units. Journal of Nursing Management, 17: 994–1001. doi: 10.1111/j.1365-2834.2009.01027.x Bragg, S. M., & Bonner, A. (2014). Degree of value alignment - a grounded theory of rural nurse resignations. Rural and Remote Health, 14(2), 1-11.     Bragg, S. M. & Bonner, A. (2015). Losing the rural nursing workforce: lessons learnt from resigning nurses. Australian Journal of Rural Health, 23: 366–370. doi: 10.1111/ajr.12251  British Columbia Nurses’ Union (April 1, 2012 to March 31, 2014). Provincial Collective Agreement Between Health Employers Associations of BC and Nurses’ Bargaining Association. Vancouver, BC.   Buckley, B. J. (2015). The Structure and Enactment of Agency in the Context of Rural Nursing Practice University of British Columbia. Retrieved from https://open.library.ubc.ca/cIRcle/collections/24/items/1.0166132 (Original work published 2015)  Bushy, A. (2006). Nursing in rural and frontier areas: issues, challenges and opportunities. Harvard Health Policy Review, 7(1), 17-27.  Canadian Institute of Health Information (CIHI). (2006). Summary Report: How Healthy Are Rural Canadians? An Assessment of Their Health Status and Health Determinants. A component of the initiative, “Canada’s Rural Communities: Understanding Rural Health and Its Determinants”. Canadian Institute for Health Information. Ottawa, Ontario.  Canadian Nurses Association. (2008). Code of Ethics for Registered Nurses: 2008 Centennial Edition. Ontario, Ottawa: Author. Canadian Nurses Association. (2008). Ethics, relationships and quality practice environments. Ethics in Practice. Ontario, Ottawa: Author. College Registered Nurses of British Columbia. (2012). 100 Years of Nursing Regulation. Retrieved from: https://www.crnbc.ca/crnbc/Documents/Centennial/download/CRNBC-Centennial.pdf ETHICAL IMPLICATIONS OF RURAL NURSES’ WORK  54	College Registered Nurses of British Columbia. (2008). Fitness to Practice: The Challenge to Maintain Physical, Mental and Emotional Health. Retrieved from https://crnbc.ca/Standards/Lists/StandardResources/329FitnesstoPractice.pdf Craig, J.V. & Smyth, R.L. (Eds.). (2012). Evidence-Based Practice Manual for Nurses (3rd ed.). Edinburgh: Churchill Livingstone: Elsevier.  Crotty, M. (1998). Foundations of Social Research: Meaning and Perspective in the Research Process. Thousand Oaks: Sage Publications Ltd.   Department for Environment, Food & Rural Affairs (DEFRA) (2002). A Guide to Rural-Proofing: Considering the Needs of Rural Areas and Communities. DEFRA: London. Retrieved from http://www.ofmdfmni.gov.uk/rural.pd  Des Meules, M., Pong, R., Lagace, C., Heng, D., Manuel, D.G., Pitblado, J.R., et al. (2006). Canadian Population Health Initiative. An Assessment of Their Health Status and Health Determinants. How healthy are rural Canadians? Canadian Institute for Health Information. Ontario: Ottawa.  Dillman, D. (2000). Mail and Internet Surveys: The Tailored Design Method. Toronto, ON: John Wiley.  Doane, G. H., & Varcoe, C. (2015). How to Nurse: Relational Inquiry with Individuals and Families in Changing Health and Health Care Contexts (1st ed.). Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins.  Dummer, T. J. B. (2008). Health geography: Supporting public health policy and planning. Canadian Medical Association Journal = Journal de l'Association Medicale Canadienne, 178(9), 1177-1180. doi:10.1503/cmaj.071783  Forbes, D.A., & Edge, D.S. (2009). Canadian home care policy and practice in rural and remote setting: challenges and solutions. Journal of Agromedicine, 14, 119-124.   Grzybowski, S., Kornelsen, J., & Cooper, E. (2007). Rural maternity care services under stress: The experiences of providers. Canadian Journal of Rural Medicine : The Official Journal of the Society of Rural Physicians of Canada = Journal Canadien de la Médecine Rurale: Le Journal Officiel de la Société De Médecine Rurale Du Canada, 12(2), 89-94.  Human Resources and Skills Development Canada. (2013). Canada Student Loan Forgiveness for Family Doctors and Nurses Application Form. Retrieved from: http://www.canlearn.ca/eng/common/documents/forms/forgiveness.pdf Hunsberger, M., Baumann, A., & Blythe, J. & Crea, M. (2009). Sustaining the rural workforce: Nursing perspectives on worklife challenges. National Rural Health Association, Winter, 17-25.  ETHICAL IMPLICATIONS OF RURAL NURSES’ WORK  55	Jackman, D., Myrick, F & Yonge, O. (2010). Rural nursing in Canada: a voice unheard. Online Journal of Rural Nursing and Health Care, 10(1), 60-69.  Kaasalainen, S., Brazil, K., Williams, A., Wilson, D., Willison, K., Marshall, D., Taniguchi, A. & Phillips, C. (2014). Nurses' experiences providing palliative care to individuals living in rural communities: aspects of the physical residential setting. Rural and Remote Health, 14(2), 1-13.   Kulig, J. C., Stewart, N., Penz, K., Forbes, D., Morgan, D., & Emerson, P. (2009). Work setting, community attachment, and satisfaction among rural and remote nurses. Public Health Nursing (Boston, Mass.), 26(5), 430-439. doi:10.1111/j.1525-1446.2009.00801.x Kulig, J., Andrews, M.E., Stewart, N., Pitblado, R., MacLeod, M., Bentham, D., D'Arcy, C., Morgan, D., Forbes, D., Remus, G. & Smith, B. (2008). How do rural nurses define rurality? Australian Journal of Rural Health, 16, pp. 28-32. doi:10.1111/j.1440-1584.2007.00947.x Kulig, J., Kilpatrick, K., Moffitt, P. & Zimmer, L., (2013). Rural and Remote Nursing Practice: An Updated Documentary Analysis. Lethbridge: University of Lethbridge. RRN2-02 Kulig, J., Thomlinson, E., Curran, F., Nahachewsky, D., MacLeod, M., Stewart, N., & Pitblado, R. (2003). Rural and Remote Nursing Practice: An Analysis of Policy Documents. Lethbridge, AB: University of Lethbridge. R03-2003.  Lambert, L., Brown, K., Segal, E., Brophy, J., Rodes-Cabau, J. & Bogaty, P. (2010). Association between timeliness of reperfusion therapy and clinical outcomes in ST-Elevation Myocardial Infarction. JAMA, 303(21): 2148-2155. doi:10.1001/jama.2010.712.   Lenthall, S., Wakerman, J., Opie, T., Dollard, M., Dunn, S., Knight, S., MacLeod, M. & Watson, C. (2009). What stresses remote area nurses? current knowledge and future action. Australian Journal of Rural Health, 17(4), 208-213. doi:10.1111/j.1440-1584.2009.01073.x  MacKinnon, K. A. (2008). Labouring to nurse: the work of rural nurses who provide maternity care. Rural and Remote Health, 8(4), 1-15.   MacKinnon, K. A. (2010). Rural nursing in Canada. M. McIntyre & C. McDonald (Eds), Realities of Canadian Nursing: Professional, Practice, and Power Issues (3rd ed. pp. 18-28). Philadelphia, PA: Lippincott Williams & Wilkins.  MacKinnon, K. A. (2012). We cannot staff for ‘what ifs’: The social organization of rural nurses’ safeguarding work. Nursing Inquiry, 19(3), 259-269. doi:10.1111/j.1440-1800.2011.00574.x  ETHICAL IMPLICATIONS OF RURAL NURSES’ WORK  56	Macleod, M. L. P., & Zimmer, L. V. (2005). Rethinking emancipation and empowerment in action research: Lessons from small rural hospitals. Canadian Journal of Nursing Research, 37(1), 68-85.  MacLeod, M. L., Kulig, J. C., Stewart, N. J., Pitblado, J. R., Knock, M., Banks, K., D'Arcy, C., Forbes, D., Lazure, G., Martin-Misener, R., Medves, J., Morgan, D., Morton, D., Remus, G., Smith, G., Thomlinson, E., Vogt, C., Zimmer, L. & Bentham, D. (2004). The Nature of Nursing Practice in Rural and Remote Canada. Canadian Health Services Research Foundation: Ottawa.  MacLeod, M. L. P., Lindsey, A. E., Ulrich, C. H., Fulton, T., & John, N. (2008). The development of a practice-driven, reality-based program for rural acute care registered nurses. Journal of Continuing Education in Nursing, 39(7), 298-304. doi:10.3928/00220124-20080701-03  Manhas, K. P., & Mitchell, I. (2015). (Dis)-trust in transitioning ventilator-dependent children from hospital to homecare. Nursing Ethics, 22(8), 913-927. doi:10.1177/0969733014551598 Mills, J., Field, J., & Cant, R. (2011). Rural and remote Australian general practice nurses' sources of evidence for knowledge translation: A cross-sectional survey. International Journal of Evidence-Based Healthcare, 9(3), 246-251. doi: 10.1111/j.1744-1609.2011.00220.x  Ministry of Health of British Columbia (January, 2015). Rural Health Service in BC: A Policy Framework to Provide a System of Quality Care. Policy discussion Paper. British Columbia: Vancouver.   Mitura, V. & Bollman, RD. (2003). The Health of Rural Canadians: A rural-urban comparison of health indicators. Rural and Small Town Canada Analysis Bulletin. Vol4, No. 6. (October 2003). Statistics Canada.  Molanari, D. L., Jaiswal, A., & Hollinger-Forrest, T. (2011). Rural nurses: lifestyle preferences and education perceptions. Online Journal of Rural Nursing & Health Care, 11(2), 16-26.   Molinari, D. L., & Monserud, M. A. (2008). Rural nurse job satisfaction. Rural and Remote Health, 8(4), 1055.  Molinari, D., & Monserud, M. (2009). Rural nurse cultural self-efficacy and job satisfaction. Journal of Transcultural Nursing, 20(2), 211-218 8p. doi:10.1177/1043659608330350  Moules, N., MacLeod, M., Thirsk, L. & Hanlon, N. (2010). "And then you'll see her in the grocery store": the working relationships of public health nurses and high-priority families in northern Canadian Communities. Journal of Pediatric Nursing 25, 327-334. doi:10.1016/j.pedn.2008.12.003  ETHICAL IMPLICATIONS OF RURAL NURSES’ WORK  57	Musto, L. C., Rodney, P. A., & Vanderheide, R. (2015). Toward interventions to address moral distress: Navigating structure and agency. Nursing Ethics, 22(1), 91-102. doi:10.1177/0969733014534879  Nagarajan, K. V. (2004). Rural and remote community health care in Canada: Beyond the Kirby panel report, the Romanow report and the federal budget of 2003. I, 9(4), 245-251.   Nelson, W., Pomerantz, A., Howard, K., & Bushy, A. (2007). A proposed rural healthcare ethics agenda. Journal of Medical Ethics, 33(3), 136–139.  O' Lynn, C., Luparell, S., Winters, C. A., Shreffler-Grant, J., Lee, H. J., & Hendrickx, L. (2009). Rural nurses' research use. Online Journal of Rural Nursing & Health Care, 9(1), 34-45.  Opie, T., Dollard, M., Lenthall, S., Wakerman, J., Dunn, S., Knight, S., & MacLeod, M. (2010). Levels of occupational stress in the remote area nursing workforce. Australian Journal of Rural Health, 18(6), 235-241 7p. doi:10.1111/j.1440-1584.2010.01161.x  Pampalon, R., Martinez, J. & Hamel, D. (2006). Does living in rural areas make a difference in rural Quebec? Health & Place. 2006; 12(4): 421-435. Pitblado, R., Koren, I., MacLeod, M., Place, J., Kulig, J., & Stewart, N. (2013). Characteristics and Distribution of the Regulated Nursing Workforce in Rural and Small Town Canada, 2003 and 2010. Prince George, BC: Nursing Practice in Rural and Remote Canada II. RRN2-01 Place, J., MacLeod, M., Johnston, S. & Pitblado, R. (June, 2014). Nursing Practice in Rural and Remote British Columbia: An Analysis of CIHI's Nursing Database. Prince George, BC: Nursing Practice in Rural and Remote Canada II. RRN2-01-1   Place, J., MacLeod, M., John, N., Adamack, M., & Lindsey, A. E. (2012). "Finding my own time": examining the spatially produced experiences of rural RNs in the rural nursing certificate program. Nurse Education Today, 32(5), 581-587. doi:10.1016/j.nedt.2011.07.004 Polit, D.F. & Beck, C.T. (2012). Nursing research: Generating and assessing evidence for nursing practice. (9th ed.). Philadelphia: Lippincott Williams & Wilkins.  Pong, R., DesMeules, M. & Lagace, C. (2008). Rural-Urban Disparities in Health: How does Canada fare and how does Canada compare with Australia? Australian Journal of Rural Health (2009) 17, 58-74. doi: 10.1111/j.1440-1584.2008.01039.x  Reid, F. C. (2013). Lived experiences of adult community nurses delivering palliative care to children and young people in rural areas. International Journal of Palliative Nursing, 19(11), 541-547. doi:10.12968/ijpn.2013.19.11.541  ETHICAL IMPLICATIONS OF RURAL NURSES’ WORK  58	Rodney, P., Doane, S. H., Storch, J., & Varcoe, C. (2006). Workplaces: Toward a safer moral climate: The authors make the case for strengthening the moral climate of nursing, an integral aspect of safe health-care delivery. Canadian Nurse, 102(8), 24-27.  Rodney, P., Kadyschuk, S., Liaschenko, J., Brown, H., Musto, L. & Snyder, N. (2013). Moral agency: relational connections and support in Storch, J., Rodney, P. & Starzomksi (Eds.). Toward a Moral Horizon: Nursing Ethics for Leadership and Practice (2nd ed.) (pp. 358-383). Toronto: Pearson-Prentice Hall.  Rodney, P. & Varcoe, C. (2012). Constrained agency: The social structure of nurse's work. In Baylis, F., Hoffmaster, B., Sherwin, S. & Borgerson, K. (Eds) (pp. 97-114). Health Care Ethics in Canada (3rd ed.). Toronto: Nelson Education.  Romanow, R. (2002). Building our values: The future of health care in Canada. Ottawa: Commission on the Future of Health Care in Canada, Government of Canada.  Rosenthal, K. (2005). What rural nursing stories are you living? Online Journal of Rural Nursing & Health Care, 5(1), 37-47.   Sackett, D., Richardson, W., Rosenberg, W. & Haynes, R. (1997). Evidence Based Medicine: How to Practice and Teach EBM. New York: Churchill Livingston.  Sandelowski, M. (1986). The problem of rigor in qualitative research. Advances in Nursing Science 8(3), 27-37.  Sibley, L. M. & Weiner, J. P. (2011). An evaluation of access to health care services along the rural-urban continuum in Canada. BMC Health Services Research, 11(20). doi:10.1186/1472-6963-11-20  Siemens, J. (2015). Analysis of the Ministry of Health Policy Initiative, “Rural Health Services in BC: A Policy Framework to Provide a System of Quality Care”. NURS 590 Self-Directed Study. Unpublished. University of British Columbia, BC.   Statistics Canada. (2009, September 22). 2006 census: Portrait of the Canadian Population in 2006: Subprovincial Population Dynamics. Ottawa, Ontario: Author. Retrieved from http://www12.statcan.ca/census-recensement/2006/as-sa/97-550/p17-eng.cfm  Statistics Canada. (2011). Census Agglomeration of Williams Lake, British Columbia. Retrieved from: http://www12.statcan.gc.ca/census-recensement/2011/as-sa/fogs-spg/Facts-cma-eng.cfm?LANG=Eng&GK=CMA&GC=950  Stewart, N., D’Arcy, C., Kosteniuk, J., Andrews, ME, Morgan, D., Forbes, D., MacLeod, M., Kulig, J., & Pitblado, R. (2011). Moving on? Predictors of intent to leave among rural and remote RNs in Canada. The Journal of Rural Health. 27, 103-113. doi: 10.1111/j.1748-0361.2010.00308.x  ETHICAL IMPLICATIONS OF RURAL NURSES’ WORK  59	University of British Columbia. (2014). Guidelines - MSN Scholarly Practice Advancement Research Project (SPAR) - NURS 595. School of Nursing, University of British Columbia, Vancouver, Canada.   Varcoe, C., Pauly, B. & Laliberte, S. (2011). Intersectionality, Justice, and Influencing Policy. In B. S. Bolaria & H. D. Dickinson (Eds.), Health, illness and health care in Canada (4th ed.) (pp. 122-150). Toronto: Nelson.  Varcoe, C., Pauly, B., Webster, G., & Storch, J. (2012). Moral distress: Tensions as springboards for action. HEC Forum, 24(1), 51-62. doi:10.1007/s10730-012-9180-2  Williams, A. & Kulig, J. (2012). Health and place in rural Canada. In Kulig, J. & Williams, A. (2012). Health in Rural Canada. Vancouver: UBC Press.  Winters, C., Thomlinson, E., & O'Lynn, C. et al. (2006). Exploring rural nursing theory across borders. In H. Lee & C. Winters, (Eds.), Rural Nursing (2nd ed.) (pp. 27-39). New York: Springer Publishing. Winters, C.A., Lee, H.J.,  Besel, J., Strand, A., Echeverri, R., Jorgensen, K.P. & Dea, J,E. (2007). Access to and use of research by rural nurses. Rural and Remote Health. 7(3), 758-768. World Health Organization. (2010). Increasing access to health workers in remote and rural areas through improved retention: Global policy recommendations. Geneva, Switzerland: World Health Organization.  Zibrik, K. J., MacLeod, M. L. P., & Zimmer, L. V. (2010). Professionalism in rural acute-care nursing. Canadian Journal of Nursing Research, 42(1), 20-36.           ETHICAL IMPLICATIONS OF RURAL NURSES’ WORK  60	Appendix A: Summary of the Energizing Experiences Energizing experiences were separated into Canadian and International experiences and were placed into the following table for review.  Appendix A: Energizing Experiences In Rural Canada Kulig et al. (2009) National • "going home or being home" (p. 436) • "I grew up in this community and I love rural life" (p. 436) • RNs reported being more satisfied with their community as size increased. (positive correlation) • "I grew confident in my abilities as a nurse and grew to enjoy the level of independence involved in working here" (p. 436) • "I love life in the country where I can live with my family" (p. 436) • "the land, the solitude, the independence, the vigor, the harsh realities, the sublime beauty" (p. 437) • rewarding work • more genuine and personal relationships with clients • lifestyle, slower pace, recreation (eg boating) • more personal • "rural nursing is not a job; it is a lifestyle"(p. 437) • rewarding Buckley (2015) BC AC/Comm • "you really grow. it's not for everybody" (p. 130) • "mutually respectful collaborative working relationships with most rural physicians" (p. 186) • "unspoken reciprocity of shared trust" (p. 187) • friendships with HCPs MacKinnon (2008) BC PHN/Comm. • smaller community programs have "more maneuverability and less bureaucracy and better relationships with committed members of the community" (p. 6) • valued opportunities for professional education Zibrik, MacLeod & Zimmer (2010) AB/BC AC • Generally, visibility as a professional in the community was a benefit that allowed nurses to feel like a trusted and respected member of the community. (p. 25) • seen as leaders in their community (p. 26) • strong teamwork (p. 28) • staff cohesiveness (p. 28) Hunsberger, Baumann, Blythe & Crea (2009) Ontario Rural Hospital  • rewarding • diversity of roles and tasks • variety of work • "thrived on the challenge of the work" (p. 20) • "I like the challenge, what is hard... is also the good thing" (p. 20) • work was meaningful (p. 21) • strong commitment and connection to patients, colleagues and community (p. 21) • unique environment • "it's a wonderful feeling to be able to intervene on someone that you know and do the right thing to help them" (p. 21) • inseparable personal and professional role • autonomy with patients • "many intangible rewards" ETHICAL IMPLICATIONS OF RURAL NURSES’ WORK  61	Kaasalainen et al. (2014) Ontario Comm.   • witnessing community care for its members (p. 6) • strong relationships with family members • providing a 'good death' as described on (p. 9) Energizing Experiences International Reid (2013) Scotland Comm. • "rewarding to deliver care... but devastating at the same time" (p. 4) • privilege to provide care Molanari, Jaiswal & Hollinger-Forrest (2011) US various practice settings • landscape • education • emergency care training • lifestyle Rosenthal (2005) US hospital nurses • Subthemes: (p. 44) • caring for known person - has a profound impact on the nurses "heart and soul" Molinari & Monserud (2005) US various practice settings • autonomy • decision making,  • job and patient variety • collaboration • participants were generally satisfied with work and lifestyle, least satisfied appeared to be nurses without children or were single (p. 213) Molinari & Monserud (2008)  US Hospital nurses • "interactions with patients, work schedule/hours, autonomy, skills, small facility, work variety, the amount of responsibility with the job and positive feelings about their jobs" (p. 6 • "supportive, encouraging, helpful, cheerful, and positive co-workers were most satisfying" (p. 6 • "adequately trained supervisors with good leadership skills" (p. 7) • "flexibility in work and scheduling" (p. 7) • "I know everyone" (p. 8) • Variety of skills, practice areas and patients. (p. 8) • "care giving and interacting with patients and families most satisfying" (p. 8) • "pride in the profession" (p. 8) • lifestyle, recreational activities, climate and social activities (p. 8) Bragg & Bonner (2014) Australia various practice settings • "shared values" = necessary supports and resources to provide a high standard of care such as adequate staffing, good communication with nursing hierarchies and budget allocations that were conducive to a high level of care provision. " (p. 4) • enjoy going to work  • satisfaction with work • being in a supportive environment • teamwork • collaboration • co-existence and co-agreement with organization Bragg & Bonner (2015) Australia various practice settings • "a greater value alignment = more retention" (p. 267) (more hypothesized than proven) • decision making • interaction with nurses, nurse managers, doctors and patients (p. 369) ETHICAL IMPLICATIONS OF RURAL NURSES’ WORK  62	Appendix B: Summary of the Distressing Experiences Distressing experiences were separated into Canadian and International experiences and were placed into the following table for review.  Distressing Experiences in Rural Canada MacLeod et al. (2004) National various practice settings  • "we try and be all things to all people - maybe it is kind of bad" (p. 13) • "I remember being up in this same community and working 36 hours straight, no sleep, no break, nothing" (p. 13) • The community chief said, "if we didn't do what we had to do they were going to ban us from the community" (p. 14) • communities with different cultures (p. 14) • difficulty communicating the complexities and character of their practice (p. 15) • planners and admin unfamiliar with the realities of their practice context (p. 15) MacKinnon (2012) Eastern BC Rural RNs who provide maternity care.  • tension between concerns of providing safe care in their setting and awareness of standards and guidelines for their specialty (p. 262) • lack of human resources (small casual pool) • lack of work to maintain casual pool (p. 262) • significant turnover in experienced staff (p. 262) • novice nurses with <5 years of experience in nursing (p. 262) • "feeling is complete panic... and then we don't have the beds; we don't have the staff" (RN, p.262) • Unable to provide one-to-one care as outlined in their guidelines 'not meeting the standard of care' (p. 262)  • overall, this article notes the constraints that a rural nurse experiences due to the nature of their work which often impedes their ability to provide care that meets the standards of their specialty.  • Tension between nurses who desired to maintain safety while physicians wanted to maintain their skills  • Noted that nurses not only had to have the qualifications but 'feel' they were qualified. This notes that qualified means much more than the certificate as they do not apply a rural lens... • Noted sense of fear in the article that nurses would find themselves in high risk situations without adequate human, technical or organizational supports that would ensure safety of the client.  • being on-call, with or without pay, to ensure skilled RNs were available • No budget in several communities to pay nurses to be on call for emergencies and/or mentoring (p. 263) • "because rural nurses feel responsible to their patients and neighbors, some nurses were providing their services for free" (p. 263) • rural nurses are being told about the scarcity of resources (MacKinnon, 2012; Rodney & Varcoe) and that "health care is too expensive" (p. 264). "This increases rural nurses’ willingness to comply with the cutbacks and efficiencies proposed by local managers" (p.264) [this is not local generally, it comes from a de-centralized location unaware of how their decision impacts the community but the nurses are aware] • Nurses feel frustrated that staffing is "determined by trends and averages" and not responsible to the needs of the community and "does not take into account what front-line nurses know about the needs of people at a given moment in time" (p. 264) • Nurse managers - money for equipment but not staffing (p. 265) • "You would sometimes have a situation where some nights I would get here and I look and it's two inexperienced [nurses] on shift at the same time" (RN, p. 265) • Overall, staffing is often distressing.  ETHICAL IMPLICATIONS OF RURAL NURSES’ WORK  63	Stewart et al. (2011) national various practice settings • more likely to leave with being on call • advanced decision making and/or practice • increasing remote Buckley (2015) AC Comm. • "we're it" (p. 126): "practice unpredictability, professional isolation, increased responsibility, and the practice challenges to provide nursing care with limited and, at times, unpredictable resources" (p. 126) • limited orientation to role • increased risk to patient and nurse safety d/t to lack of physician support (p. 129) • work 'never stops' (p. 129) • critical decision making with limited resources (e.g.,immediate assistance, insufficient authority, lack of education) is anxiety inducing (p. 130) • experienced trauma of participating in critical incidents (p. 131) • anxiety about safety and unpredictability of the work  • lack of respect from larger health care centers "lack of common professional courtesy" (p. 135) • "public nurse shaming" (p. 156) • rural policy gaps make it difficult for rural nurses to carry out urban policy (p. 162) • "lost sleep, felt distraught and disgusted" due to the treatment of a palliative care patient.  • decreased staffing levels and risk of patient safety • feeling unsafe (p. 167) d/t lack of physician support • angst working alone at night (p. 167) • "revolving doctor door" (p. 185) • having to do what they believed was best for the client with limited resources and then "ask for forgiveness" (p. 201) to follow rule or provide care. All morally distressing: moral pain of inaction or moral distress of public shaming. - • "structural inflexibility and lack of availability, affordability, acceptability, and timeliness in access to health care services" (p. 205) often led to nurses having to make decisions that were distressing. • "structural violence as nurses experiences blaming discourse for the nature of their work as they felt responsible for living and working in the isolated conditions" (p. 234) • "the day-to-day reality of managing high acuity patients under less than ideal working conditions with few resources was experienced as ethically challenging" (p. 245) as nurses felt constrained to provide care that required more than they were able to provide due to various organizational and structural constraints related to geographic context of rural nursing practice. MacKinnon (2008) BC PHN/Comm. • Competing for funding • inadequate staffing • Greater variety of patients • administrative work such as time consuming provincial forms. • lack of resources/health services • "I find it difficult... here you kind of have to be everything to everybody, or try" (RN33, (p. 8) • Difficulty to provide services across many programs.  • Lack of education for their work, teaching what they did not really understand themselves. • Loss of a baby in the community is devastating. • Lack of skilled maternity nurses at the local hospital.  • Guidelines state one-to-one nursing for active labour but that isn't provided and staffing states "We can't staff for what ifs" • Sometimes relationships are strained with other HCPs d/t the nurse trying to safeguard babies (p. 9) ETHICAL IMPLICATIONS OF RURAL NURSES’ WORK  64	• Never leaving work for PHNs, never handing over the work. • Higher workload r/t community relationships that is not recognized in the 'core deliverables' of PHN. • lack of mentorship  • concerns for liability • "cold or judgmental" treatment of urban nurses "Rural nurses told us many stories where they had experienced 'moral distress'." (p. 9) • "scared to death" r/t inexperience • decreased access to education and experience. • Experienced nurses are distressed that their voice remains unheard. Requests to rehearse skills or be provided safe staffing levels are not being acted upon (p. 10). Moules, MacLeod, Thirsk & Hanlon (2010) Northern BC PHNs • Challenge between separating personal and professional self. "I hate getting into that I'm the professional and you're the client kind of relationship" (p. 332) • "You know you're not supposed to be giving people things. That's really hard when they have nothing, no food in the cupboard... no diaper, no milk... and I did take her some meat once that I had in the freezer because she didn't have any. And I thought how do you walk away and think my kids are going to eat but hers aren't eating" (p. 332) • clients need basic items that are not available or they cannot afford so nurses feel compelled to supply them such as a stroller etc. • "How do you walk away?" (p. 332) Grzybowski, Kornelsen & Cooper (2007) BC Nurses who provided maternity care. • challenge of remaining competent (p. 91) • Noted tensions between the provision of services but the need to maintain competence with the provision of such services. It was a noted dilemma for HCPs. • anxiety r/t lack of experience with skills and maintaining competence Zibrik, MacLeod & Zimmer (2010) BC/AB AC • "the bad thing is [that] sometimes you just can't get away from work" (p. 25) • difficulty managing obligations and expectations from community members (p. 25) • pressure to always be professional, courteous, helpful and friendly. (p. 25) • Felt obligated to be extra accommodating to community members (p. 25) • "it's important to do your best for them" (p. 25) • stress r/t negative 'word of mouth' (p. 25) • expected to set a good example for the community as leaders (p. 26) • challenges maintaining confidentiality (p. 26) • "it's up to us" and "no one to fall back on" (p. 27) • being prepared is challenging (p. 27) • need to be familiar with each area (p. 27) • Need to be familiar with equipment, policies and protocols (p. 28) • "lack of access to up-to-date equipment and resources" (p. 28)* • "lack of access to equipment, specialized education and adequate staffing" (p. 28)* • *6/8 felt constrained by these factors • feel demeaned by nurses in bigger hospitals (p. 28) • lack of educational support by employer due to lack of funding (p. 29) • lack of staff drain their energy and work satisfaction (p. 29) Hunsberger, Baumann, Blythe & Crea (2009) Ontario • stressful  • stress having to maintain such a broad skillset • caring for rare, unfamiliar or life-threatening conditions (p. 20) • great responsibility - "I am the trauma team" (p. 20) • being re-assigned to a different area to work ETHICAL IMPLICATIONS OF RURAL NURSES’ WORK  65	Rural Hospital RNs • concern for safety and feel at risk due to unpredictable nature of work and isolation. • Pressure to make decisions and act beyond scope of practice (p. 20) • lack of specialty support services. An experienced urban ICU nurse was distressed d/t lack of support of physician, RT etc. in rural setting (p. 20) • "Growing acuity and complexity of their patient population was making their roles more stressful" (p. 20) • transporting patients to other "personally and professionally demanding" (p. 21) • "felt demeaned because staff in tertiary care settings did not appreciate the challenges of transporting unstable patients and disputed their clinical decisions" (p. 21) • maintaining competency is challenging • "it makes it scary" (p. 21) • lack of separation from personal and professional - lots of calls at home etc. • lack of control over schedules and work status • inconvenient work schedules that interfere with personal life • lack of full time work leading to several part-time jobs • noted change in work ethic with "new graduates making their lives as important as their careers" (p. 21) • work is exhausting • burnout • having to stay when there is no one to replace the nurse • attempts to acquire more education go unrewarded (p. 21) Kaasalainen et al. (2014) Ontario Comm. • isolating • lack of anonymity of the client • stress d/t change in system negatively impacting work life and quality of care (p. 6) (eg centralization) • less time with patients • "increased quantity of their work while work quality has declined" (p. 6) • increased responsibilities on caregivers of patients • increased driving, paperwork, unpaid time and lack of compensation for items such as gas • declining number of RNs  • declined vacation time • challenges r/t accessing resources and supplies to provide optimal palliative care • "disjointed care" such as initial assessments being done over the phone (p. 8) • extreme filth or poverty in client’s homes • doctors unaware of their clients Kulig et al. (2009) Western national various practice settings • exhausting • frustrating • "sometimes a frightening opportunity to learn about yourself in a cross-cultural context" (p. 437) • Nurses who isolate themselves have poorer job satisfaction Distressing Experiences: International  MacLeod et al. (2004) National various practice settings    • "we try and be all things to all people - maybe it is kind of bad" (p. 13) • "I remember being up in this same community and working 36 hours straight, no sleep, no break, nothing" (p. 13) • The community chief said, "if we didn't do what we had to do they were going to ban us from the community" (p. 14) • communities with different cultures (p. 14) • difficulty communicating the complexities and character of their practice (p. 15) ETHICAL IMPLICATIONS OF RURAL NURSES’ WORK  66	 • planners and admin unfamiliar with the realities of their practice context (p. 15) Reid (2013) Scotland Comm. • underprepared to deal with emotional impact of death of CYP • lack of palliative care education in pre-registration programs • difficulty navigating professional road (p. ) Molanari, Jaiswal & Hollinger-Forrest (2011) US various practice settings • Lack of emergency training Rosenthal (2005) US rural hospital nurses Subthemes: (p. 44) 1. feelings of never having enough knowledge 2. "trial by fire" 3. being the most qualified in a situation 4. significant experiential learning 5. confidence gained with education/certification  • Self-reliance (stay calm, "you're it") Molinari & Monserud (2005) US various practice settings • supervisor's lack of support • poor communication • lack of encouragement Molinari & Monserud (2008)  US rural hospital nurses • "lack of compensation for working weekends, control over work conditions, recognition of their work from their superiors, for career advancement opportunities, amount of encouragement and positive feedback, and benefit packages" (p. 6) • "salary and amount of responsibilty" (p. 6) • "co-workers did not help, support, appreciate or provide positive recognition" (p. 7) • "lack of communication or perceived lack of respect" (p. 7) • "scheduling issues" (p. 7) • "amount of responsibility the job demanded" (p. 8) • schedules - working weekends/holidays, not having sick time, scheduled breaks, restrictions on vacation time.  • staffing shortage compounding issues r/t scheduling (p. 8) • salary and benefits (p. 8) Bragg & Bonner (2014) Australia various practice settings • "resignation occurred when nurses were unable, or unwilling, to realign their personal values to changed organizational values that have occurred over time in rural hospitals" (p. 4) • "nurses seek to realign their values in order to create balance (or alignment) with those of the organization in which they work but when they are no longer able to achieve balance, a values threshold is reached which in turn eventually leads to resignation" (p. 4) • unshared values = increased frustration and decreased satisfaction • nurses felt they had to compromise patient care to align with organizational values • inadequate staffing • inadequate resources for patient care • inexperienced staff ETHICAL IMPLICATIONS OF RURAL NURSES’ WORK  67	• unfair allocation of funds to managers while cuts were impacting resources (food, linen etc) for patients were cut (p. 6) • compromised integrity • personal health issues (high BP, headaches, emotional stress, crying, palpitations, chest pain, GI problems) • feeling devastated, shattered confidence • negatively impacting home life Bragg & Bonner (2015) Australia various practice settings • "conflict between nurses' personal values - how nurses perceive nursing should occur - and organizational values - how the hospital enables nurses to carry out nursing." (p. 267) • inflexible work schedule  • perceived need to make changes to improve patient care. • there is a sense that there was a lack of trust/communication with nurses and their managers which caused them to resign. I think the resigning was their way of enacting their agency or power.  • limited options for work in rural settings if they want to change place of work • managers • "it's devastating to watch, the system's being pulled apart for people running these nasty games, it's got nothing to do with what the town requires" (Judy, age over 50, nursing for 31 years)      ETHICAL IMPLICATIONS OF RURAL NURSES’ WORK  68	Appendix C: Summary of the Relational Experiences Relational experiences were separated into Canadian and International experiences and were placed into the following table for review.  Appendix C: Relational Experiences MacLeod et al. (2004) National • "community size, distance from other centres, climate, and the demographics of its people influence both the focus of the nurses' attention and their work, not to mention the resources available to them" (p. 13). Kulig et al.  (2009) Western national various practice settings • being needed  • challenging Stewart et al.  (2011) National • "intention to leave significantly positively associated with perceived stress and level of education, and negatively associated with years employed in one's primary agency" Buckley  (2015) BC AC/Comm. • "living and working in a rural setting... is a privilege and it's a burden at the same time" (p. 125 • inseparable personal and professional identity • perception of what acceptability could be rewarding or distressing. MacKinnon (2008) BC PHN/Comm. • complex • requiring broad knowledge base • "you're everything" in the hospital (RN7, (p. 7) • infrequency of various events Moules, MacLeod, Thirsk & Hanlon (2010) Northern BC PHNs • seeking reciprocity with the community (p. 329) • "24 hours a day I am a PHN. 24 hours a day, I'm a woman. And 24 hours a day, 7 days a week, I am a community member" (p. 333) Zibrik, MacLeod & Zimmer (2010) BC/AB AC • "socially embedded in their community" (p. 25) • high degree of visibility in the community • must be flexible and able to handle unanticipated events (p. 26) •  Hunsberger, Baumann, Blythe & Crea (2009) Ontario Rural Hospital RNs • "rewarding or stressful depending on context" (p. 19) • caring for patients with common illnesses/health issues (familiarity) (p. 20) • autonomy • decision maker • unpredictability in practice and work arrangements (p. 20) • "you have to be extremely independent and self-confident" • "rarely discussed remuneration"(p. 21) Kaasalainen et al. (2014) Ontario Comm. • "strong sense of community and trust with its members. mostly viewed positively" (p. 6) • interactions with other members of team either positive, negative or neutral    ETHICAL IMPLICATIONS OF RURAL NURSES’ WORK  69	Relational Experiences: International Rosenthal (2005) US hospital nurses noted themes: 1. Need to be a generalist (p. 42) 2. need to function as jack of all trades (p. 42) 3. expected to fill non-professional roles usually done by other HCPs or support services such as EKG, blood draw, RT (p. 43) 4. Lack of anonymity/role conflict (p. 43) 5. Insider/outside - takes a long time to become part of the community (p. 43) 6. Professional isolation • Fluid Role (p. 43) team dynamics, trust, rapport (p. 43) Molinari & Monserud (2005) US Various rural nurses • older nurses were more confident provide care to patients with chronic/complex patients • urban and rural may impact nurses' self-efficacy  Molinari & Monserud (2008)  US Hospital nurses • Interactions with staff • lifestyle, recreational activities, climate and social activities (p. 8) Baernholdt & Mark (2009) US Hospital nurses • rural/urban factors that influences job satisfaction: • availablity of support services, commitment to care and autonomy.  • positive significant relationship between turnover rate and work complexity and unit vacancy rates                               ETHICAL IMPLICATIONS OF RURAL NURSES’ WORK  70	Appendix D: Summary of Key Points Used to Inform the RNCP Curriculum Development   1. Preferred courses and content for rural acute care postbasic continuing education are those that reflect the realities and needs of everyday practice.  2. Rural RNs prefer multimethod educational delivery approaches that enable them to gain academic credit while remaining in their homes and workplaces and reserving travel for gaining new skills and experiences.  3. Rural RNs prefer learning approaches that develop skills and abilities needed for multispecialist practice in settings where resources are few and distances are great.  4. A practice-driven, academically linked approach to continuing education sets up new possiblities for responsive, relevant curriculum development in rural acute care nursing.    (MacLeod, Lindsey, Ulrich, Fulton & John, 2008, p. 303)  MacLeod, M. L. P., Lindsey, A. E., Ulrich, C. H., Fulton, T., & John, N. (2008). The development of a practice-driven, reality-based program for rural acute care registered nurses. Journal of Continuing Education in Nursing, 39(7), 298-304. doi:10.3928/00220124-20080701-03  

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