Studying nursing in a rural setting: are students adequately supported and prepared for rural practice? A pilot study.

INTRODUCTION
A rural nursing program has a vital role in improving the recruitment and retention of nurses in rural and remote settings. A small pilot study was conducted to explore the views and experiences of the first cohort of undergraduate nursing students who completed a rurally based bachelor of nursing program which commenced in 2002 in Renmark, South Australia. The participants were eight current undergraduate nursing students who were part of the first cohort of nursing students nearing completion of the program. The pilot study set out to explore support provided to rural nursing students studying in a rural setting; to investigate whether rural nursing students feel adequately prepared for rural clinical practice near completion of the nursing program; to identify the challenges and highlights of studying rurally; and to explore the probability of retention and recruitment of future nursing graduates in a rural setting.


METHODS
The method used was a descriptive, exploratory, web-based survey. Quantitative data were limited to descriptive statistics of demographic characteristics, career goals, graduate nurse program and future employment intentions, level of support, preparation for practice, challenges and highlights of rural study and clinical placements. Qualitative responses to open-ended questions were content analysed to identify common themes.


FINDINGS
This study found between two and four participants indicated they received no support from academic, administrative staff and clinical facilitators from the city campus. Five participants (63%) indicated they received no financial support during their studies. Seven of the participants (88%) surveyed, indicated an intention to undertake a graduate nurse program and the same number indicated they would be living in a rural or remote area in 5 years time. Six participants (75%) indicated they were prepared with regard to their 'attitude' towards their future practice as a registered nurse. The study identified some of the challenging issues of a rurally based program, such as 'realising that if you miss a day you are actually missing a whole week's worth of lectures', as well as the positive and unique aspects of rural study, 'not having to leave the family to travel to the city'.


CONCLUSION
This study indicates the rural placement of the bachelor of nursing program has been of benefit to this particular community and is a positive outcome for the South Australian rural nursing workforce. The study shows that students actively sought nursing employment in a rural setting, and identifies highlights experienced by students and the advantages associated with remaining at home (as opposed to relocating) while enjoying the benefits of smaller class sizes. The challenges of rural study were issues such as limited lecture times, compared with the city campus, which often caused a disproportionate workload for rural students on alternate weeks during the study term. The quality of the delivery of some lectures was also an issue for some students. This study determined that a lack of support was encountered by students, and that further investigation is warranted. Greater consideration will be required to address the delivery of the program together with the future availability and accessibility of further university rurally based nursing programs.


Introduction
A rural nursing program has a vital role in improving the recruitment and retention of nurses in rural and remote settings.In Australia and internationally 1 there is a shortage of nurses, particularly in rural and remote areas 2 .
The purpose of this small pilot study (hereafter known as the FURCS study) was to explore the views and experiences of the first cohort of undergraduate nursing students to complete the Flinders University Bachelor of Nursing (BNg) program at Renmark in South Australia's Riverland region.
The course operates at Flinders University Rural Clinical School (FURCS), Renmark, South Australia, which is one of only two rural locations in South Australia where most of the undergraduate nursing curriculum is delivered internally via face-to-face lectures and clinical workshops; and one of 25 rural campus locations in Australia.According to the Rural, Remote and Metropolitan Area (RRMA) classification system, which categorizes areas according to remoteness 3 , Renmark is zoned 'rural' because it is an urban centre with a population of less than 10 000 (Table 1).
On completion of the BNg program, a graduate nurse program (GNP) is offered by four of the five Riverland hospitals.The 12 month program is designed to consolidate the skills of a new graduate nurse in a supportive learning environment.GNPs can increase retention rates by allowing new graduates to gain specialty skills 4 that are often in short supply in rural and remote areas 5 .
Recent literature claims that rural health is different and these differences (social, cultural and socio-political) should be considered when training health professionals in a rural setting 6 .Issues which confront consumers and health professionals in rural health include lack of or smaller services, lack of resources and the added expenses related to distance 6 .These challenges, therefore, will confront any student who is studying and living in a rural environment.An American study found that nurses chose to practice in a rural setting for mainly personal reasons, such as enjoying rural lifestyle and spousal employment 11 .The author suggests that it is for personal reasons, such as location of friends and family, and employment opportunities, that a rural nurse is more likely to stay once they have completed a locally based program; this is endorsed by previous studies 12- 14 .Another study by Taylor and Neill suggest that this stability is only more likely for mature-aged students/nurses 15 .Several studies argue that health professionals who are more familiar with life in a rural community, are more interested in rural practice postgraduation 11,16,17 .
The literature demonstrates that students who are educated in a rural setting will return to that setting on graduation; however, this may not be the case in the Riverland region.
The FURCS study set out to: (i) explore whether nursing students are adequately supported while studying in a rural setting; (ii) investigate whether rural nursing students feel adequately prepared for rural clinical practice near completion of the nursing program; (iii) identify and evaluate both the challenges and highlights of studying rurally; and (iv) explore the retention and recruitment of future nursing graduates in a rural setting.There was no intention to generalize any inferences of the research to the general population; rather, this research has been undertaken for evaluation purposes, as well as to generate discussion.

Participants and setting
The target group consisted of 15 students who were currently

Survey instrument
The tool used to gather the data was an online survey (Appendix I).The survey was sent to the students as a web page attached as a separate file to an email.Information was sought about the demographics of the participants.Questions in the survey were both closed (quantitative data) and openended (qualitative data).The survey was presented under three headings: 'About You', 'Future Nursing Goals' and 'Challenges and Highlights'.To conclude, the students were invited to comment on the challenges, highlights and issues relevant to studying rurally.

Data collection
Students were approached by the researcher at the end of a final teaching session to explain the research, and a letter of introduction invited students to participate in the study.The survey was posted online 2 weeks prior to the students' final clinical block placement, and the participants were asked to submit responses within 2 weeks.The participants responded online; their email addresses were not available on the web survey form, thus providing anonymity.The surveys were collected and collated by a third party (administrator) before being given to the researcher to ensure confidentiality, due to the small numbers in the study and because the principal researcher was a lecturer based at the campus.

Ethical considerations
This research project was granted ethics approval by the

Flinders University Social and Behavioural Research Ethics
Committee in August 2004.

Data analysis
The quantitative data were analysed using Perseus Survey Solutions XP vers 5.

Findings
Demographic data were collated into tables using the Perseus Survey Software which displayed results using frequencies and percentages.Four of the participants (50%) were in the 20-29 year age group and the other four were over the age of 40 years.In the over 40 age group, three participants were aged between 40 and 49 and one was aged between 50 and 59.All participants lived in a rural or regional area and were employed at the time of the study, either in nursing or a health profession.Table 2 presents the demographic data.

Advantages of studying rurally
Participants were asked to comment on what they believed to be the advantages of studying rurally.Students were aware of the importance of being able to study locally, as summarized by the following student: 'Staying in own environment, with family and able to continue with own employment to be able to continue to manage financially'.
A positive aspect of smaller class sizes was described by one student as: 'Being in a smaller group that has supported one another…' The same student felt that '…more individual time spent with local lecturers and their support' was another highlight of rural study.

Perceived level of support
The participants were asked to rate, using a five point Likert scale, the level of support they felt they received during the program in areas nominated by the researcher (Table 3).A score of 1 on the scale indicated the participant felt unsupported during the program, while a score of 5 indicated the participant felt well supported.

Perceived level of preparation for practice
The participants were asked to rate, using the Likert scale between 1 and 5, how they felt about their 'readiness/preparedness' to practice as a registered nurse in the future (Table 4).A score of 1 on the scale indicated the participant felt inadequately prepared to practice as registered nurse, while a score of 5 indicated the participant felt very well prepared.Six participants (75%) indicated they were prepared with regard to their 'attitude' towards their future practice as a registered nurse, and five participants (63%) felt adequately and well prepared for practice 'overall'.

Career goals and future employment
Seven participants (88%) indicated they would be applying for a GNP -four of the respondents had applied locally, and Lack of support has been discussed in a previous study 7 and was found to be one of the negative aspects of studying rurally.However, the author suggests the issue of rural students travelling to Adelaide could be addressed either by providing some financial support or reducing the number of visits.A rural nursing project in Georgia, USA, reported that nursing students were reimbursed for travel expenses secured through funding from a local non-profit health education organisation and were provided with free overnight accommodation by the hospitals 18 .Such support was viewed in terms of providing a positive experience to increase the recruitment of new graduates 18 .
There has recently been an increase in the opportunity for nursing students to apply for scholarships, especially those in rural areas who wish to pursue a rural career; however, most of these are means tested.In fact, the most recent recommendation from the recent National Review of Nursing Education suggests that all new scholarships should be offered for 3 years 19 .recognised as beneficial to the future of healthcare delivery in rural environments, as well as potentially able to assist in building a culture of learning and research within rural communities 20 .Teleconferencing and videoconferencing is useful for staff and students in tutorials, but Hays cautions that it cannot replace the value of face-to-face delivery 21 .

Advantages of studying rurally
The findings of the FURCS study suggest that these students benefit from being able to stay at home with family and friends, from reduced travelling, and from the ability to continue in their employment.The students in this study indicated they were able to gain further support from family and friends, as well as being able to form a close supportive network with other nursing students due to small class sizes.
For the local community, there is also the long-term advantage of being able to retain graduates.This is not dissimilar from the rural health strategy for medical students to undertake training in a rural setting 22 .Local support and improved retention of rural nurses are significant aims of locating a nursing program in the rural Riverland of South Australia.
Common elements of the highlights of rural study indicated by students in the FURCS study included being close to family; support from family, colleagues, local staff and the local community; and working within that community.These are similar to the findings of a Tasmanian study 10 where the support and respect of the community was noted as a positive aspect of studying rurally.

Career goals and future employment
The majority of the nursing students indicated that they would be living in a rural area in 5 years time.This could be associated with one or more of the following factors: coming from a rural background 12,16,17 , having a positive rural clinical experience 23,24 , personal/family reasons 11 , or that 50% of students were mature-aged 15 .However, retention levels of the new nursing graduates may depend on the graduates' career aspirations because there is less turnover of staff in rural areas 4 .A Queensland study found that as nursing practice moves from cities to more remote areas, the roles of nurses become more diverse 25 .Multiple role responsibilities would explain why the same study found rural and remote nurse executives were less likely to apply for another position 25 .The Queensland study also found that the lack of opportunities and barriers to professional development did not promote career advancement for those nurses outside the metropolitan area 25 .Therefore, to 'stay rural' may affect the career path of the new graduate nurse.
Some students in the FURCS study indicated a desire for further study in other areas of nursing or midwifery.The problems of accessing further rurally based university programs and of professional isolation, however, continue to pose a challenge for nurses in rural and remote settings 19 .
The provision of professional and educational opportunities is a major factor which determines whether nurses remain in a rural setting 9 .

Limitations
The

Implications and recommendations
The lack of support and some of the perceived challenges of 18.What do you believe are the advantages of studying in Renmark as opposed to the city?
19.What do you believe have been the highlights and/or positive aspects of studying rurally for you so far?

20.
Please make any further comments on anything that particularly relates to the challenges of studying rurally or the future of your nursing career?
Although your response to this survey is anonymous, we are required to remind you that the web is not a secure medium for the transmission of data.
Submit Survey enrolled in the bachelor of nursing program at Flinders University, Adelaide, South Australia, and based at the Renmark campus.The undergraduate students had commenced at FURCS in 2002 and were due to complete the program at the end of 2004.The students were personally handed an information sheet introducing the study, inviting them to participate.Eight of the 15 students returned the survey, a response rate of 53%.
two in the city (Adelaide), one in a large rural centre (Mildura, Victoria).Figures from the first cohort of undergraduate nursing students studying at the Renmark campus demonstrate that 11 of the 15 students (73%) have graduated and become registered nurses.Of those 73% nursing graduates, eight have been retained in the region (73%) and all gained employment as registered nurses.Initially, four of the participants indicated an intention to specialise in a particular branch of nursing once they had completed the program.However, five participants indicated that they had changed their goals since commencing the program.Two participants mentioned that their goal was to now make it through the program.Four participants indicated they would be going on to further study (one to study law).One stated: 'I now know how stressful university life is there is no way I would ever consider doing another degree'.Another participant also mentioned stress, stating: 'The study load along with the added stress in my life has taken its toll'.When asked where they might be living in 5 years time, six participants (75%) indicated that they may be living in a rural area, one participant indicated they may be living in a metropolitan area, and one indicated intention to live in a remote area.Challenges encounteredOne challenge mentioned was 'Having to go to Adelaide for option and compulsory topics [due to] finding own accommodation and finances…'.One participant commented on the structure of the timetable in Renmark as: 'Realizing that if you miss a day you are actually missing a whole week's worth of lectures'.Participants stated challenges, such as: 'We don't have our own librarian', 'lack of resources', 'Rural students have missed out on…info, support and lecture material'.One participant described the '…communication with people in the city' as a challenge.One student advised: 'Physical presence of lecturers all the time is a must, the audio tapes and video [taped] lectures were definitely not a success…' In summary, the above findings provide vital information about the BNg program from a rural perspective, and includes the advantages, challenges, perceived level of support, suggestions and indications about future plans of the nursing students.Discussion Perceived lack of support It is of concern that one nursing student clearly stated their goal had now changed: 'Not…[to become] a midwife due to the study involved and the lack of support for rural students…'.The FURCS study indicates that some rural nursing students felt unsupported financially and unsupported by city campus staff.It is difficult to know in such a small and mostly quantitative study what, in fact, led the students to perceive this lack of support.This may warrant further investigation.

Table 3 :
Level of support as perceived by bachelor of nursing students supported=5, adequate support=4, a little supported=3, undecided=2, not supported=1.FURCS, Flinders University Rural Clinical School.Challenges of rural studyOne of the challenges of studying rurally included the timetabling of topics.Participants in the FURCS study often studied two sessions of a topic in one day, instead of only one session, and then the next session for this topic was not held until 2 weeks later.This was done to assist with the reduction of travel time for the students, as well as the visiting lecturers from the city -a 4 hour drive away.The disadvantage to this approach is that students have to cope with a heavy content load.The school of nursing and midwifery is addressing this issue by the use of direct streaming technology which allows the Renmark campus to have a computer link-up with the Adelaide campus for delivery of lectures (Unpubl.report, Bachelor of Nursing Review, Flinders University, Adelaide, 2005).The advantage of direct streaming is that students can either watch the lecture/session 'live' or at another time online as a video file.The pilot for this approach commenced in March 2006.It is hoped the new technology will reduce the need to change timetables, will spread the content load, and will assist the timetable to be equivalent to Adelaide.Students having to view video-taped or audio-taped lectures is not ideal learning; rural students should have the same quality learning opportunities as their metropolitan counterparts.The use of video-streaming in the BNg program will potentially give rural nursing students greater access to educational opportunities.Telemedicine has been main limitation of the FURCS study was use of nonrandom sampling technique, combined with a very small sample size.Another limitation of the study was the low response rate (53%) which may have influenced the findings, not representing all views of the first cohort of nursing students.The distribution of the questionnaire (by email) to the students during their examination and clinical placement period was prone to selection bias.A follow-up distribution of the questionnaire may have increased the response rate; however, this was less likely due to the students undertaking exams and completing assignments.Ideally, the survey should have been administered on completion of the program.The author acknowledges that due to these limitations the sample is unlikely to be representative of the population.

2 . 3 . 4 . 5 . 6 . 13 .FURCSFinancial 14 . 15 . 16 . 17 .
rural study include the problems associated with distance, curriculum delivery and lack of resources which may have implications for retention of nursing students in the BNg program and their future nursing careers.This FURCS study recommends that the lack of support, as perceived by the rural nursing students, be explored further, using a combined qualitative and quantitative methodological approach to discover how rural nursing students can feel more supported during a university program.Further research is also recommended to explore the financial impact of the scholarships for rural students.Further research could be expanded to follow the careers of consecutive cohorts using a longitudinal design.A recent report by Hays discusses the importance of the same curriculum being deliverable at more than one site, such as the city and a rural campus, while maintaining its quality, and the management of difficulties associated with staffing, communication and information management in a rural region21 .The aim is to provide distributed learning and, although not defined by Hays, this involves the integration of technology into education and, as a result, the ability of students to access the same learning whether on campus or online26 .To provide the necessary support to both students and staff, the author advocates using the hindsight recommended by Hays, in the establishment of a rurallybased program with a goal of meeting the same educational objectives, but in different settings.Hays describes six guiding principles relating to his own experience, which include matching curriculum objectives and assessments, appropriate staffing, adequate information management and communication services and securing the necessary funding to assist with the additional expenses 21 .The challenges of studying rurally are similar to those of the distance learner.Parallel to concerns in a recent report: 'Overview of Distributed Education and Its Challenges' 26 , we must ask, 'Do students in a rural setting need and receive the same level and quality of services as the city or metropolitan based students?'This question must be considered when evaluating the quality of education and learning for rurally based students.Further academic study is vital for the diversity required of rural nurses, as well as being important in enabling high quality nursing care for the community.Therefore, this study recommends that opportunities are provided in rural settings for nurses to be able to undertake further university programs in their own region.Conclusion This FURCS study analysed students' perceptions of studying in a rural nursing university course; it highlights the importance of the need to focus on effective support for rural students.Types of support recommended for a rural nursing program include good communication, placement support, financial support and adequate resources, all factors which are similar to the barriers and challenges influencing rural health professionals and distance or distributed learning environments 21,26 .Nevertheless, most participants in this study seemed prepared for practice as rural registered nurses and signified their intention to practice in the region in the short term.This suggests the creation of a rural nursing program has been of benefit to this particular community, and is a positive result for the South Australian rural nursing workforce.Further research on this topic will be necessary to strengthen and progress the findings using subsequent cohorts, and will add to the continued and future success of the program.Please indicate your gender male female Please indicate your current (or main) type of employment Please indicate your current marital Do you have children or dependants?Yes No Which region represents where you live Please rate the level of support you have received during the program by the following: not supported undecided a little supported adequate support well supported Please rate the following items in relation to how you currently feel about your 'readiness/preparedness' to practice as a Registered Nurse in the future.inadequately prepared undecided adequately prepared well prepared very well prepared What would you say has been the the most challenging issue/s for you so far pertaining to studying rurally.Think about some of the challenges vs highlights during the program -if you could change one thing about the clinical placements, what would it be?Why? Think about some of the challenges vs highlights during the program -if you could change one thing about the curriculum, what would it be?Why?

Table 1 : Structure of Rural, Remote and Metropolitan Area (RRMA) classification
Review of the Rural, Remote, and Metropolitan Areas (RRMA) Classification Discussion Paper, Australian Government Department of Health and Ageing, March 2005; and The Rural, Remote and Metropolitan Area (RRMA) classification System, Australian Government, Department of Health and Ageing.