Advance Care Planning in Rural Montana: Exploring the Nurse's Role.

It is recommended that advance care planning take place across the lifespan. Rural populations have a heightened risk for poor quality and high cost of end-of-life care. A doctoral project was completed to assess rural nurses' knowledge, attitudes, and experiences with advance directives using the Knowledge, Attitudinal, and Experimental Surveys on Advance Directives. Descriptive statistics were used for analysis. Participants were nurses who practice in rural settings (N = 22). The average age was 46.4 years; all were white (n = 22), and the majority were baccalaureate prepared (n = 12). Practice settings were primarily in home care and hospice. Knowledge scores on advance directives were low (57%). Nurses felt confident in counseling and initiating discussions with patients and families. Less than one-half of the nurses reported they feel part of the advance care planning team. The majority reported advance directive resources and mentorship of younger nurses would be beneficial and indicated the need for additional education, training, knowledge, time, and support to better assist with advance care planning. Project results and recommendations were presented to the participating health care organization. Recommendations included workplace education, support, mentorship, resources, and education on cultural sensitivity using the rural nursing theory.

A Comparison of Environmental Concerns in Two Disparate Montana and Nevada Communities.

Asbestos refers to six fibrous minerals that occur naturally in the environment in the United States and throughout the world. Deposits may be found in soil, rocks, and deposits of other minerals such as vermiculite and talc. These naturally occurring asbestos (NOA) minerals belong to the serpentine and amphibole family of minerals. This chapter reports shared components of community-driven environmental concerns related to exposure to NOA in a rural Montana and a suburban Nevada community. The specific aim is to establish an understanding of the community and community member's primary concern(s) related to NOA in both communities. The knowledge that NOA is commonly found in areas across the United States supports the need for additional research into the health effects of environmental exposure and best-practices to reduce exposure risk while allowing communities to thrive economically.

Principal components analysis to identify influences on research communication and engagement during an environmental disaster.

OBJECTIVES: To discern community attitudes towards research engagement in Libby, Montana, the only Superfund site for which a public health emergency has been declared. STUDY DESIGN: Survey study of convenience samples of residents near the Libby, Montana Superfund site. PARTICIPANTS: Residents of the Libby, Montana area were recruited from a local retail establishment (N=120, survey 1) or a community event (N=127, survey 2). MEASURES: Two surveys were developed in consultation with a Community Advisory Panel. RESULTS: Principal components of survey 1 showed four dimensions of community members' attitudes towards research engagement: (1) researcher communication and contributions to the community, (2) identity and affiliation of the researchers requesting participation, (3) potential personal barriers, including data confidentiality, painful or invasive procedures and effects on health insurance and (4) research benefits for the community, oneself or family. The score on the first factor was positively related to desire to participate in research (r=0.31, p=0.01). Scores on factors 2 and 3 were higher for those with diagnosis of asbestos-related disease (ARD) in the family (Cohen's d=0.41, 0.57). Survey 2 also found more positive attitudes towards research when a family member had ARD (Cohen's d=0.48). CONCLUSIONS: Principal components analysis shows different dimensions of attitudes towards research engagement. The different dimensions are related to community members' desire to be invited to participate in research, awareness of past research in the community and having been screened or diagnosed with a health condition related to the Superfund contaminant.

Palliative Care in Critical Rural Settings.

The United States has 1332 critical access hospitals. These hospitals have fewer than 25 beds each and a mean daily census of 4.2 patients. Critical access hospitals are located in rural areas and provide acute inpatient services, ambulatory care, labor and delivery services, and general surgery. Some, but not all, critical access hospitals offer home care services; a few have palliative care programs. Because of the millions of patients living with serious and life-threatening conditions, the need for palliative care is increasing. As expert generalists, rural nurses are well positioned to provide care close to home for patients of all ages and the patients' families. A case report illustrates the role that nurses and critical access hospitals play in meeting the need for high-quality palliative care in rural settings. Working together, rural nurses and their urban nursing colleagues can provide palliative care across all health care settings.

Critical Care in Critical Access Hospitals.

What began as a grant-funded demonstration project, as a means of bridging the gap in rural health care, has developed into a critical access hospital system comprising 1328 facilities across 45 states. A critical access hospital is not just a safety net for health care in a rural community. Such hospitals may also provide specialized services such as same-day surgery, infusion therapy, and intensive care. For hospitals located near the required minimum of 35 miles from a tertiary care center, management of critically ill patients may be a matter of stabilization and transfer. Critical access hospitals in more rural areas are often much farther from tertiary care; some of these hospitals are situated within frontier areas of the United States. This article describes the development of critical access hospitals, provision of care and services, challenges to critical care in critical access hospitals, and suggestions to address gaps in research and collaborative care.

Descriptive analysis of the respiratory health status of persons exposed to Libby amphibole asbestos.

OBJECTIVE: Describe respiratory health and quality of life in persons exposed to Libby amphibole asbestos (LAA) contaminated vermiculite. DESIGN: Cross-sectional descriptive. SETTING: Asbestos-related disease clinic in Libby, Montana USA. PARTICIPANTS: 329 individuals exposed to LAA; mostly men, married, between 50 and 69 years; two-thirds lived in the surrounding county; one-third lived elsewhere in the state and USA. PRIMARY OUTCOME MEASURES: Chest radiograph (CXR), pulmonary function data and the St George Respiratory Questionnaire (SGRQ). RESULTS: Exposure categories included vermiculite workers=7.6%; family/household contact of vermiculite worker=32%; and environmental exposure only=60%. Of the participants, 55% had only pleural abnormalities; 5.4% had only interstitial abnormalities; nearly 21% had both abnormalities and 18% had no lung abnormality on chest x-ray. Mean forced vital capacity (FVC) 95.3% (SD=18.7); forced expiratory volume (FEV(1)) mean 87% (SD=20.2); ratio of FEV1(1)/FVC 95.5% (SD=12.0); and diffusing capacity (DLCO) of 83% (SD=21.7) of the percent predicted. The mean total SGRQ (38.5; SD=22.1) indicated a lower quality of life than healthy persons and persons with other chronic conditions. SGRQ subscale means were Symptoms 52.1 (SD=24.9), activity 49.4 (SD=26.9) and impacts 27.5 (SD=21.9). Participants with normal CXR differed significantly from those with both interstitial and pleural abnormalities on total, activity and impacts scores. For activity alone, subjects with normal CXR differed significantly from those with pleural disease; no differences were found for those with interstitial disease. Significant findings were found for smoking history across all pulmonary measures, and for exposure status, radiographic findings, age and gender for select pulmonary parameters. Subjects with any smoking history had significantly worse average total and subscale scores on the SGRQ. CONCLUSIONS: Of 329 persons exposed to LAA, the majority (182) had pleural abnormalities identified on CXR. SGRQ scores for persons with abnormalities (pleural, interstitial or both) (269) differed significantly from those with a normal CXR.

Teaching strategies to support evidence-based practice.

Evidence-based practice is an expected core competency of all health care clinicians regardless of discipline. Use of evidence-based practice means integrating the best research with clinical expertise and patient values to achieve optimal health outcomes. Evidence-based practice requires nurses to access and appraise evidence rapidly before integrating it into clinical practice. Role modeling and integrating the skills necessary to develop evidence-based practice into clinical and nonclinical courses is an important part in developing positive attitudes toward evidence-based practice, an essential first step to using evidence to guide practice decisions. The step-by-step approach to evidence-based practice proposed by Melnyk and colleagues provides an excellent organizing framework for teaching strategies specifically designed to facilitate nurses' knowledge and skill development in evidence-based practice.

Determining satisfaction with access and financial aspects of care for persons exposed to Libby amphibole asbestos: rural and national environmental policy implications.

Libby, Montana is a Superfund site and epicenter of one of the worst environmental disasters in the USA history in terms of asbestos-related mortality and morbidity. Perceptions of access and financial aspects of care were explored among a national cohort of persons postasbestos exposure and prior to a 2009 Public Health Emergency Declaration. Our findings indicated the Libby cohort was significantly less satisfied with access and financial aspects of care as measured by two PSQ-III scales when compared to an adult, chronically ill patient sample. Participants with higher levels of respiratory morbidity and depression had significantly lower satisfaction scores.

Psychosocial health status of persons seeking treatment for exposure to libby amphibole asbestos.

A cross-sectional exploratory study was conducted to describe the psychosocial health status of persons seeking health care for exposure to Libby amphibole asbestos (LAA). Health indicators including depression, stress, acceptance of illness, and satisfaction with access and financial aspects of care were obtained via electronic and paper-pencil survey. The exposure pathway and demographic data were gleaned from the health record. Of the 386 participants, more than one-third (34.5%) demonstrated significant levels of psychological distress. The oldest group of women had the lowest levels of depression and stress and the highest acceptance of illness. Gender, age, and satisfaction with financial resources were significantly related to depression, stress, and acceptance of illness. Satisfaction with access to care was significant only for stress. No differences in depression, stress, and acceptance of illness were found based on residence, exposure pathway, or insurance status.

Rural public health policy models to address an evolving environmental asbestos disaster.

The health-related dangers of asbestos exposure were recognized early in the 20th century when occupational exposure was found to be associated with excess pneumoconiosis among asbestos industry workers. Today, the epicenter for examining the public health effects and the human toll that this toxin has had on a population is located in the rural community of Libby, MT. Rurality and multideterminants of health frame both the history of asbestos-related disease and the service/policy challenges within a community dealing with chronic illness and designation as a Superfund clean-up site. Despite efforts by public health advocates to address the lingering aftermath of an environmental disaster in this community, policy gaps exist that continue to impact the population's health. The purpose of this paper is to describe the history and outcomes of asbestos exposure in a rural community and discuss 3 models that provide public health policy insights related to rural health and health care for a community affected by both a sentinel and ongoing environmental event.

The rural context and women's self-management of chronic health conditions.

OBJECTIVE: To examine the rural context and describe its influence on the self-management of chronic illness by women living in a rural setting. METHODS: The Women to Women (WTW) project is a research-based computer intervention that provides health education and peer support to rural women with chronic health conditions. Messages posted to the online support and health education chat rooms were examined to determine the characteristics of the rural context in relation to the women's illness self-management. RESULTS: 'Distance' was the overarching characteristic of the rural context that influenced the women's ability to self-manage their chronic health problems. The effect of distance was woven throughout each of the four predominant themes that emerged from the data as having influence - physical setting, social/cultural/economic environment, nature of women's work, and accessibility/quality of healthcare. These influences affected the women's self-management abilities both negatively and positively. DISCUSSION: The rural context profoundly influenced the ability of rural women to self-manage their chronic conditions. From the data, health professionals and policy-makers can glean information about the barriers to healthcare faced by rural women who are trying to manage their chronic health problems in comparative isolation.

Chronically ill rural women: self-identified management problems and solutions.

OBJECTIVE: To add to the knowledge base of illness management of chronically ill, rural women by describing the self-identified problems and solutions reported by women participants in the online health-education segment of the Women to Women (WTW) computer outreach project. METHODS: WTW is a research-based computer intervention providing health education and online peer support for rural women with chronic diseases. Messages posted to the online chat room were examined to determine the women's self-management problems and solutions. RESULTS: The self-identified problems were: (1) difficulties in carrying through on self-management programmes; (2) negative fears and feelings; (3) poor communication with care providers; and (4) disturbed relationships with family and friends. The self-identified solutions to these problems included problem-solving techniques that were tailored to the rural lifestyle. Although not all problems were 'solvable', they could be 'lived with' if the women's prescriptions for self-management were used. DISCUSSION: Glimpses into the women's day-to-day experiences of living with chronic illness gleaned from the interactive health-education discussions will give health professionals insights into the women's efforts to manage their illnesses. The data provide health professionals with information to heighten their sensitivity to their clients' day-to-day care and educational needs.

The Center for Research on Chronic Health Conditions: a strategy for enhancing rural nursing research.

Conducting nursing research with rural populations is influenced by the multidimensional characteristics of rural dwellers, the rural environment, the paucity of nurse scientists prepared and supported to conduct rural research, and institutional constraints common to academic institutions serving rural communities. Collaboration across rural academic settings is therefore integral to the success of rural nursing science. The purpose of this article is to discuss the role of the Center for Research on Chronic Health Conditions in Rural Dwellers as a strategy for overcoming the challenges of conducting rural nursing research in the rural western mountain region of the United States.

Special feature: an approach to cardiac care in rural settings.

Rural people with cardiovascular disease-and the nurses caring for them-face unique health care challenges. Obstacles facing patients living in small rural communities include lack of critical care specialists, inadequate technological support, and inconsistent or variable levels of 24-hour patient care services requiring patients to travel to distant tertiary centers for advanced cardiac care. Rural critical care nurses face reduced access to continuing education and inservice presentations, professional isolation, and lack of anonymity. This article introduces "Mr Smith," a rancher with cardiovascular disease living in a rural Western state. In so doing, it reviews the issues and challenges faced by rural patients and nurses. In addition, the article describes a continuing education course developed to enhance collaboration between nurses working in rural settings and a tertiary medical center.