Starting the Research Process

JONAVolume 41, Number 3, pp 129-137Copyright B2011 Wolters Kluwer Health | Lippincott Williams & Wilkins THE JOURNAL OF NURSING ADMINISTRATION Rural Hospital Nursing Results of a National Survey of Nurse Executives Robin P. Newhouse, PhD, RN, NEA-BC Laura Morlock, PhD Peter Pronovost, MD, PhD Sara Breckenridge Sproat, PhD, RN Objective: The objective of the study was to describe nursing characteristics in small and larger rural hospitals and determine whether differences exist in market, hospital, and nursing characteristics.

Background: A better description of nursing in rural settings is needed to understand the work context.

Methods: A national sample of rural hospital nurse executives (n = 280) completed the Nurse Environ- ment Survey and Essentials of Magnetism instrument.

Results: Larger rural hospitals are more likely than small hospitals to have a clinical ladder (32.4% vs 19.4%), more baccalaureate-prepared RNs (20.8% vs 17.1%), greater perceived economic (mean, 9.5 vs 8.5) and external influences (mean, 41.1 vs 39.8), lower shared vision among hospital staff (mean, 18.4 vs 19.4), and higher levels of quality and safety engagement (mean, 16.9 vs 16.1). Most nurses em- ployed in rural hospitals are educated at the associate degree (77.4%) level.

Conclusions: Contextual differences exist between small and larger rural hospitals. To promote the best patient outcomes, attention to contextual differences is needed to tailor nursing interventions to fit the resources, environment, and patient needs in a given healthcare setting.

America’s rural populations encounter barriers to quality healthcare. 1 These quality barriers corre- spond with an alarming increase in healthcare costs, placing a direct and specific economic burden on rural areas. 2 Rural populations are expected to experience heightened healthcare needs (aging pop- ulation and increase in minorities), greater income disparities (lower income and education than urban settings), provider price hikes, and increased de- mand for expensive technology (to which rural residents do not always have access). 2 Forty percent (1,998 of 5,010) of US community hospitals registered with the American Hospital Asso- ciation (AHA) are rural (nonmetropolitan). 3These hos- pitals provided care for 12.8% (5.1 million) of all US hospitalizations in 2007. 4The definition of Brural [is var- iable, with estimates for the rural population ranging between 10% and 28% of the US total population. 5,6 Rural was defined in this study based on the sam- pling frame from a prior study using the Office of Man- agement and Budget (OMB) pre-2003 classification system for metropolitan / nonmetropolitan areas. 7,8 This system is based on metr opolitan statistical areas (MSAs) generated by the US Census Bureau, which uses a county-level classific ation. Rural hospitals are defined as those located in counties that do not qualify as MSAs. Although the re are many alternative definitions of Brural, [the OMB definition has been JONA Vol. 41, No. 3 March 2011 129 Authors’ Affiliations: Associate Professor and Assistant Dean for the Doctor of Nursing Practice Program (Dr Newhouse),University of Maryland School of Nursing, Baltimore; Professor(Dr Morlock), Department of Health Policy and Management,Bloomberg School of Public Health, Johns Hopkins University,Baltimore, Maryland; Professor (Dr Pronovost), Department ofAnesthesiology and Critical Care Medicine, Johns HopkinsUniversity School of Medicine, Center for Innovation in QualityPatient Care, Johns Hopkins University, Baltimore, Maryland;US Army Nurse Corps (Dr Breckenridge Sproat), Walter ReedArmy Medical Center, Washington, District of Columbia. Corresponding author: Dr Newhouse, University of Maryland School of Nursing, 655 W Lombard St, Suite 516B, Baltimore, MD21201 ( [email protected] ). Funding: This study was supported by grant KO8HS015548 from the Agency for Healthcare Research and Quality. The content is solely the responsibility of the authors and does not necessarily represent the official views of the Agencyfor Healthcare Research and Quality. The information orcontents and conclusions do not necessarily represent the officialposition or policy of, nor should any official endorsement beinferred by, the Department of Defense or the US Government. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are providedin the HTML and PDF versions of this article on the journal’sWeb site (www.jonajournal.com). DOI: 10.1097/NNA.0b013e31820c7212 Copyright @ 201 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. 1 used by more than 30 federal programs to determine program eligibility and reimbursement levels. A Brural [ designation using core-based statistical area (CBSA) indicates that the area ha s a population of less than 10,000 (personal communication, AHA, March 30, 2010). BMetropolitan [designation indicates an urban- ized area with a population of 50,000 or more, and Bmicropolitan [indicates an urban cluster of population of at least 10,000 but less than 50,000. 9 Although rural settings face some of the same quality challenges as urban areas, older rural pop- ulations with higher levels of chronic illnesses have unique healthcare needs that place them at risk for suffering preventable harm. 10 Attention to quality improvement in rural settings with focused efforts on education, training, and deployment of health- care professionals is required. 10 Nursing, the largest provider of healthcare, af- fects patient outcomes. 11 In a systematic review and meta-analysis of 28 studies, better nurse staffing was significantly associated with lower mortality, fewer adverse patient events, and shorter length of stay. 11 This relationship was present in a wide range of set- tings and patients, across a variety of adverse events (hospital-acquired pneumonia, unplanned extubation, respiratory failure, cardiac arrest, and failure to rescue). 11 Patient outcomes are nurse sensitive if the outcome varies with the quantity of nurses (such as more nursing hoursperpatientorhighern urse-to-patient ratios). Patient and hospital attributes also contribute to nurse- sensitive outcomes and must be considered when examining relationships between nursing and patient outcomes. 11Rural settings are underrepresented in these studies. One-fifth of all RNs (20.8%) live in rural areas. 12 Most nurses who live in rural areas report hospitals as their primary work setting (57.5% in larger rural and 50.1% in small rural areas). 12 Compared with their urban counterparts, nurses who work in rural areas are paid lower annual salaries (average, $40,516 vs $49,627). Urban RNs typically work in urban locations (97.4%), whereas nurses living in rural areas tend to commute outside their rural lo- cations. 12 This pattern of RNs commuting outside their geographic area of residency can exacerbate the nursing shortage in rural areas. Consistent gaps exist in rural areas between predicted RN need and the number of RNs employed. 13 The Balanced Budget Act of 1997 included the Medicare Rural Hospital Flexibility Program, in- tended to support rural healthcare. 14 This program allows licensed acute-care rural hospitals to apply to become critical access hospitals (CAHs) if they meet specific criteria. Hospitals must be located in a rural area, more than 35 miles from another hospital, at least 15 miles from another hospital if in mountainous terrain or over secondary roads, or state certified as a necessary provider of healthcare services to area residents. 14 Additional requirements include main- taining an average annual length of stay of 96 hours or less, having a maximum of 25 beds, providing 24-hour emergency services, and having patient re- ferral and transfer agreements with other acute-care hospitals in place. The Medicare Prescription Drug, Improvement, and Modernization Act of 2003 in- creased the number of beds permitted to qualify as a CAH, making it easier for hospitals to convert. 15 One of the major benefits of conversion from a rural hospital designation to a CAH is that Medicare reim- burses CAHs on a cost basis rather than a capitation basis, which financially benefits CAHs. 14 There were 1,315 CAHs in the United States as of June 2010. 14 A better description of nursing characteristics is needed to understand the rural hospital work con- text. The purposes of this study were to (1) describe the characteristics of nursing in small and larger rural hospitals and (2) determine whether differences exist in the market, hospital, and nursing characteristics of small and larger rural hospitals. The term rural hospital is used to describe all rural hospitals. Small rural hospital is used to describe a rural hospital or CAH with 25 or fewer beds. A larger rural hospita l is a rural hospital with more than 25 beds.

Methods Study Population After study approval from the Johns Hopkins Medi- cine institutional review board, a national conve- nience sample of 688 rural hospital nurse executives from 47 states was invited to complete a telephone or written survey. Nurse executives worked in rural hospitals included in a prior study in which Brural [ was defined by the OMB pre-2003 classification system for metropolitan/nonmetropolitan areas. 7,8 The first 54 nurse executives received a letter of invitation with a follow-up call 2 weeks later to schedule a telephone interview. Subsequent subjects were invited to complete a written survey using a modified Dillman 16 method. 17 Respondents received a $20 gift certificate for completing the survey.

Data Sources The surveys administered were the Nursing Environ- ment Survey (NES) and the Essentials of Magnetism (EOM) instrument. 18 Nursing Environment Survey The NES was developed for use in this study. See Doc- ument, Supplemental Digital Content 1, to view the full 130 JONA Vol. 41, No. 3 March 2011 Copyright @ 201 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. 1 survey with all items, http://links.lww.com/JONA/A43.

Items were constructed based on a qualitative study 19 and review of instruments used in prior studies. 7,8,20,21 Table 1 includes a description of the NES scales, definitions, number of ite ms in each scale, response format, and range of total sc ores. Adequate estimates of reliability and validity were obtained (item test-retest reliability [ rQ0.444 to 0.999], content validity index of 1.0, construct validity of factors using exploratory factor analysis with varima x rotation, a cutoff eigen- value of 1.0, and a lower limit of 0.40 for factor loadings to create internally consistent scales [ !Q.74 except for quality and safety which was a = .68]). The scales are market (economic influences, isolation, and external nursing influences), hospital (shared vision and quality and safety), and nursing (nursing chal- lenges and evidence-based practice [EBP]). A 4-item response format is used for al l items. Additional detail on the psychometric evaluation of the NES is pub- lished elsewhere. 22 (See Table, Supplemental Digital Content 2, which shows a description of the market and hospitals scales, Cronbach !’s , i t e m s a n d f a c - tor loadings, http://links.lww.com/JONA/A44. See Table, Supplemental Digital Content 3, which shows a description of the item means and stan- dard deviations for the market and hospital scales, http://links.lww.com/JONA/A45.) Nursing challenges include 4 items: EBP, main- taining competency of staff, fostering ongoing edu- cation, and staff nurse academic education. EBP includes 7 barriers to enabling EBP: education of staff, availability of expert, availability of educator, availability of mentor, wearing many hats, lack of familiarity with EBP, and no time. Nursing challenges and EBP scale items can be reviewed in Figure 1.

Essentials of Magnetism The EOM instrument measures the attributes of the work environment that nurses find essential to quality care. 18 Acceptable estimates of reliability in- clude test-retest reliability and internal consistency (Cronbach !between .80 and .90 for all scales ex- cept clinically competent/support for education, != .78). Validity was supported through principal component factor analysis and content validity greater than 0.90 for all scales. Scales in the EOM include clinically competent, support for education, RN-physician relationships, autonomy, control over nursing practice, nurse man- ager support (managerial and leadership), cultural values, and adequacy of staffing. 18 Hospital Characteristics Hospital data for employers of responding nurse ex- ecutives were obtained from the 2006 AHA Annual Survey. 23 Analysis Data were entered, and all analyses were conducted using SPSS 15 (SPSS Inc, Chicago, Illinois). Contin- uous data were analyzed with independent ttests and categorical data with 22tests. A Mann-Whitney U test was used if assumptions for the ttest were not met. PG.05 was considered significant. Results The response rate was 41% (280/688), which varied by US Census Bureau region (56% Northeast, 45% Midwest, 34% South, and 45% West). In the final sample, the distribution of rural hospitals by region was as follows: 10% Northeast (28/280), 36% Midwest (101/280), 38% South (45/280), and 16% West (45/280). The locations of hospitals included in this sample were similar to national estimates for rural hospitals (South, 38% vs 37%; Midwest, 36% vs 40%; Northeast, 10% vs 7.1%; and West, 16% vs 16%). 4 Compared with nonrespondents, most Table 1. NES Scales Scales Market, Hospital, or Nursing Variables Definition No. of Items (Range of Score) MarketEconomic influences The impact of changes in hospital revenue on nursing 4 (4-16)Isolation The impact of physical and professional remoteness 4 (4-16)External nursing influences Important forces outside the organization that influence nursing (such as nurse recruitment) 12 (12-48) HospitalShared vision Extent to which the group works together for common patient-centered goals 6 (6-24) Quality and safety Engagement in quality and safety activities 6 (6-24) NursingNursing challenges Major issues confronted by nursing 4 (4-16)EBP barriers Major issues to implementing EBPs 7 (7-28) JONA Vol. 41, No. 3 March 2011 131 Copyright @ 201 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. 1 respondents were from the South and Midwest (46% vs 36%), had lower average daily census (ADC) (43 vs 55), and were less likely to be a mem- ber of a system (40% vs 47%). There were no dif- ferences in hospital types (larger vs small).

Nurse Executive Characteristics Nurse executive respondents were primarily white (95%) and female (92%), with an average of 5.9 years in their current positions. There were no sig- nificant differences between larger and small rural hospital nurse executive characteristics. Character- istics are also similar to national samples of nurse executives from acute-care hospitals (white, 95% vs 96%; female, 92% vs 94%; average years in current position, 5.9 vs 5.6). 24 Hospital Characteristics Table 2 compares the characteristics of small and larger rural hospitals. The ADC for larger rural hos- pitals (mean, 53.6) was higher than small rural hos- pitals (mean, 21.1). More larger rural hospitals were Joint Commission (JC) accredited (84.7% vs 25.5%).

Both types of hospitals had similar distance away from educational settings (42.6 miles) and were as likely to be members of a system (38.6%) or network (33.2%) or to be Magnet Aaccredited or seeking ac- creditation (11.4%). Significantly more small hospitals Table 2. Hospital Characteristics Larger Rural (n = 186) Small Rural (n = 94) Total (n = 280) Hospital Characteristics Mean (SD) Mean (SD) Mean (SD) ADC a 53.6 (53.3) 21.1 (22.3) 42.6 (47.7) b Miles away from education c 40.5 (68.2) 48.6 (43.1) 43.2 (61.0) Proportion (n) Proportion (n) Proportion (n) Member of system a 40.9 (76/186) 34.0 (32/94) 38.6 (108/280) Member of a network a 31.2 (58/186) 37.2 (35/94) 33.2 (93/280) JC accredited a 84.7 (133/184) 25.5 (24/94) 56.5 (157/278) b Magnet Aor seeking c 13.7 (24/175) 6.7 (6/89) 11.4 (30/264) Rural CBSA 27.2 (50/184) 79.8 (75/94) 45.0 (125/278) b aSource: AHA 2006 Annual Survey. 23 bPG.05 using 22test for categorical and ttest for continuous variables. cSource: Nurse Executive Survey. Figure 1. EBP barriers and nursing challenges scales, directions, items, and internal consistency.

132 JONA Vol. 41, No. 3 March 2011 Copyright @ 201 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. 1 (79.8%) than larger hospitals (27.2%) were desig- nated as Brural [by CBSA criteria. RN Characteristics Table 3 describes RN attributes. Larger hospitals with more beds employ more RNs than small rural hospitals (mean, 129.9 vs 36.4). RNs predominantly hold associate degrees in nursing (ADN) (77.4% in both settings, with more baccalaureate nurses [BS] working in larger rural hospitals [20.8% vs 17.1%]).

Clinical ladders are available more often in larger (32.4%) than in small (19.4%) rural hospitals. In both settings, nurses usually float across units (91.1%), with similar vacancy (9%) and turnover (17%) rates. Nurses are occasionally represented by unions (18.2%), and nurse executives perceive that RN wages are competitive (84.5%).

Perceptions of Market, Hospital, and Nursing Influences Table 4 compares larger and small rural hospital nurse executives’ perceptions of market, hospital, nursing, and EOM total scores. Larger rural hospital nurse executives report higher mean scores than those in small rural hospitals in the following areas: ex- ternal nursing influences (41.1 vs 39.8), economic influences (9.5 vs 8.5), and hospital quality and safety activities (16.9 vs 16.1). Larger rural hospital nurse executives report lower scores than those in small rural hospitals in 1 area, shared vision (18.4 vs 19.4). Table 3. RN Characteristics RN Characteristics Larger Rural (n = 186) Small Rural (n = 94) Total (n = 280) Mean (SD) Mean (SD) Mean (SD) No. of RNs employed 129.9 (136.8) 36.4 (30.0) 98.9 (121.3) a No. of RNs who left the organization in FY 2005 13.0 (13.7) 4.4 (4.6) 9.8 (12.0) a Turnover rate b 0.18 (0.57) 0.15 (0.21) 0.17 (0.47) Vacant full-time equivalent c 8.7 (16.8) 2.0 (2.3) 6.4 (14.0) Vacancy rate 0.10 (0.20) 0.07 (0.11) 0.09 (0.17)Percentage of RNs with AA degree 75.5 (17.1) 80.7 (15.3) 77.4 (16.6) a Percentage of RNs with BS degree 20.8 (14.7) 17.1 (15.1) 19.4 (14.9) a Percentage of RNs with MS degree 3.2 (3.7) 2.2 (2.9) 2.9 (3.5) a Proportion (n) Proportion (n) Proportion (n) RNs represented by unions 21.1 (39/185) 12.9 (12/93) 18.3 (51/278)Have a clinical ladder 32.4 (60/185) 19.4 (18/93) 28.1 (78/278) d RNs float across units 93.0 (173/186) 88.2 (82/93) 91.4 (255/279)Wages are competitive 85.5 (159/186) 83.9 (78/93) 84.9 (237/279) aPG.05 using Mann-Whitney Utest. bNumber of RNs who left the organization in 2005 / average number of nurses employed 100. cSource: AHA Annual Survey. 23 dPG.05 using 22test for categorical and ttest for continuous variables. Table 4. Market, Hospital, and Nursing Factors Market, Hospital, and Nursing Factors Larger Rural (n = 186) Small Rural (n = 94) Total (n = 280) Domains Mean (SD) Mean (SD) Mean (SD) MarketExternal nursing influences 41.1 (4.6) 39.8 (5.0) 40.7 (4.8) a Economic influences 9.5 (2.2) 8.5 (2.1) 9.2 (2.2) a Isolation 8.7 (2.2) 8.8 (2.6) 8.7 (2.4) HospitalShared vision 18.4 (2.8) 19.4 (2.7) 18.8 (2.8) a Quality/safety engagement 16.9 (2.3) 16.1 (2.7) 16.6 (2.5) a NursingEvidenced-based practice barriers 20.4 (4.5) 21.2 (4.7) 20.7 (4.6)Nursing challenges 10.5 (2.7) 11.1 (2.5) 10.7 (2.6)EOM total score 305.0 (33.6) 304.3 (33.3) 304.8 (33.4) aPG.05 using ttest. JONA Vol. 41, No. 3 March 2011 133 Copyright @ 201 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. 1 No differences exist between larger and small rural hospital settings with regard to the perceptions of isolation. In addition, there is no significant correlation between isolation and CBSA designation for larger, small, or all rural hospitals. There was no difference in perceptions of mar- ket, hospital, or nursing influences for network or nonnetwork hospitals. There were significant differ- ences for system and nonsystem hospitals. System hospital nurse executives report a higher level of external nursing influences (mean, 42 vs 40, PG.001) and higher quality and safety activities (17 vs 16, P= .045) compared with nonsystem hospitals.

Discussion Although nursing in small and larger rural hospitals have multiple similarities, the settings are contex- tually different in market and hospital character- istics. The nurse executive, hospital, and nursing characteristics and influence of hospital and market factors on nursing are further discussed.

Rural Hospital Nurse Executives The characteristics of nurse executives in this sam- ple are similar in larger and small rural hospitals.

These characteristics are also similar to attributes of nurse executives in national samples that represent both rural and nonrural settings.

Hospital Significant differences exist between small and larger rural hospitals in ADC, JC accreditation, and rural designation by CBSA definitions. It is expected that hospitals with more beds (larger rural) have a higher ADC. Larger rural hospitals (compared with small) are accredited by the JC. The JC began to accredit small rural hospitals (CAHs) in 2001. 25 Accredita- tion is associated with improvements in processes and infrastructure. In a survey of 107 hospitals, JC accreditation was significantly related to a higher level of patient safety system implementation. 26 The JC has been a leader in measuring hospital quality, realizing significant improvements in process meas- ures over time. 27 It is unknown whether accredita- tion is linked to better patient outcomes, as studies demonstrate inconsistent results. 28,29 Significantly more small rural hospitals were lo- cated in areas designated as rural with lower popu- lation density. In addition, 73% of larger and 20% of small rural hospitals were located in a micropolitan or metropolitan areas using CBSA. This is not un- usual, as counties used to designate CBSAs contain both rural and urban settings. 30 For example, using 2005 classifications, approximately 13% of the population considered to be metropolitan is rural. 30 Nursing Significant differences exist between small and larger rural hospitals in the number of RNs employed, educational preparation of RNs, and availability of clinical ladders. It is not unexpected that larger hospitals would employ more RNs given their higher bed count. It is important to note that larger rural hospitals are more likely to employ a higher percent- age of BS-prepared RNs and have a clinical ladder available more often. The level of BS-prepared RNs within organiza- tions is important, as some evidence suggests that more BS-prepared nurses in acute-care hospitals are associated with better patient outcomes. 31 Beyond the evidence, the complex nature and demands of inpatient admissions require a high level of expert practice and critical thinking. The degree held by most nurses in rural hospitals was an ADN, which is consistent with other studies. 12 It is important to note that, in this sample, rural hospitals were ap- proximately 43 miles from educational settings. The remote location of these hospitals makes re- cruitment of BS graduates difficult. In addition, the distance is a deterrent to the availability of RN-to- BS or BSN programs if the program is offered on site instead of through distance education. Clinical ladders structure levels of nursing prac- tice, with higher levels indicating advanced expertise.

Clinical ladders are linked to nurse retention and increase nurses’ professional responsibility with accompanying reimbursement. 32 Clinical ladders are a satisfier that is important for nurse retention.

Given the concern that projections of rural nurse workforce shortages may be underestimates, 13 rural nursing needs to be a priority focus for professional development, recruitment, and retention efforts.

Influence of Market, Hospital, and Nursing Forces on Nursing Significant differences exist between small and larger rural hospital nurse executives in the perceptions of market (external nursing in fluences, economic influ- ences) and hospital factors (hospital quality and safety activities and shared vision). There were no significant differences in the influence of nursing factors.

Market There were significant differences between small and larger rural hospitals in the perceived influence of external and economic factors. External forces in- clude pressures to report core quality measures as well as various legislative changes. Larger rural hospitals 134 JONA Vol. 41, No. 3 March 2011 Copyright @ 201 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. 1 are JC accredited more often. It is not surprising that nurse executives experience a higher impact from external sources with the acceleration of quality and safety initiatives and the advent of public reporting of quality metrics. With lower patient volume and dif- ferences in the population, quality measures for rural hospitals require specificity for the rural context. 33 Lower volumes may prevent rural hospitals from re- porting some quality measures, because there is a minimum number of patients required for the denom- inator data. In addition, th ere may be other indicators important to quality such as internal systems to iden- tify patients who require interventions or care not available in the rural hos pital setting. A more ap- propriate measure of qualit y may be timely transfer of patients to settings where required care can be provided. Larger rural hospital nurse executives feel the burden of economic infl uences. Conversion to CAHs may have buffered the negative economic effects for small rural hospitals, because Medicare reimbursement is cost based. Larger rural hospitals are typically reimbursed for care by federal, state, and private insurers on a per case basis. Per case reimbursement creates an incentive to reduce costs per admission and results in financial losses if efforts are unsuccessful. It is interesting to note that there is no relation- ship between the perception of isolation and CBSA designation for larger, small, or all rural hospitals in this sample. This indicates that the perception of isolation is not related to population density. The sense of isolation may be overcome through rela- tively easy solutions, such as linkages with profes- sional organizations and quality or EBP networks of similar rural hospitals.

Hospital There were significant differences in the perception of small and larger hospital factors that influence nursing in the areas of hospital quality and safety activities and shared vision. Nurse executives per- ceive a higher shared vision in small rural hospitals.

This higher shared vision may be related to the nature of a smaller organization and more direct interac- tions with hospital staff and physicians. Shared vision is an essential interdisciplinary attribute, with team members committing to common patient-centered goals. As disciplines work together and bring unique contributions to the care of the patient, better outcomes result. For example, lower rates of patient complications and death are associated with surgical teams that share information. 34 Lower quality and safety engagement for small rural hospitals may reflect the scale of the work- force, with fewer staff available to lead quality and safety initiatives. Rural hospitals have reported lower adherence to evidence-based guidelines in national public reporting efforts. 35 High-risk, low- frequency procedures, such as neonatal resuscitation, may be problematic, with variances in knowledge and skills for nurses and physicians. 36 Shared vision and quality and safety engage- ment have positive independent effects for better nursing practice environments. 22 Increased quality and safety initiatives and attention to evidence- based guidelines are important components in per- formance improvement in all settings.

Nursing There were no significant differences in the per- ception of small and larger hospital factors that influence nursing. Nurse executives in both settings perceive the same nursing challenges and EBP barriers. The perception of professional satisfaction of nurses is also similar. This would indicate that similar strategies to promote adoption of EBPs could be implemented in both settings.

Implications The results of this study have implications for rural hospital nurse executives, policy makers, and re- searchers. Nurse executives in small rural hospitals should consider how they can enable professional development of their staff, including the use of clinical ladders. Networking with other small hospi- tals or partners to develop programs that can be accessed remotely can engage nurses in local, state, and national initiatives. Engagement in quality and safety initiatives can be promoted by linkages with professional organizations. For example, the Na- tional Rural Health Association should be accessed to share best practices, network, and provide con- tinuing education specific to rural settings. Nurse executives in larger rural hospitals should focus on developing teams focused on a common patient-centered goal to promote a shared vision within their organization. Team building among disciplines will foster shared vision and promote high levels of proficiency for high-risk, low-volume procedures. Policy makers at the state and national level will need to endorse programs to promote baccalaureate education for nurses. All rural hospitals employ a large number of ADN-prepared nurses, with more employed by small rural hospitals. To promote BS education for RNs, linkages should be fostered with colleges and universities that offer RN-to-BS pro- grams locally or through distance education. Increas- ing the presence of BS-prepared nurses within the JONA Vol. 41, No. 3 March 2011 135 Copyright @ 201 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. 1 rural hospital setting will prime the organization with staff that can interpret and apply new evidence as it emerges. Researchers can use these results to inform in- terventions tailored to the rural setting. Small and larger rural hospitals will require different strategies to promote the adoption of best practices. Acute-care settings with less resources and professional develop- ment opportunities will require a higher level of mentorship and expert consultation.

Study Limitations There are 3 limitations to this study. First, the NES was developed for this study, so psychometric testing is limited. However, the available psychometric data suggest the instruments performed well with accept- able estimates. Second, the perspective of a single respondent (the nurse executive) represented each hospital. The NES focuses on content for which the nurse executive is the best source of information.

Third, the sample was a convenience sample repre- senting hospitals with lower census than the sam- pling frame and variation in response rate by region.

Despite drawing the study sample nationally, sam- pling bias may limit the generalizability of results.

Conclusion This study describes the characteristics and context of rural hospital nursing. When comparing larger and small rural hospitals, differences exist in market, hospital, and nursing attributes. Standards of nursing care apply to all settings. To promote the best patient outcomes, attention to contextual differences is needed to tailor nursing interventions to fit the re- sources, environment, and patient needs in the given healthcare setting. Results of this study are informa- tive regarding these contextual differences. References 1. Agency for Healthcare Research and Quality. Health care disparities in rural areas: selected findings from the 2004National Healthcare Disparities Report. Updated 2005. Avail-able at http://www.ahrq.gov/research/ruraldisp/ruraldispar.htm. Accessed February 7, 2010. 2. McBride TD. Why Are Health Care Expenditures Increasing and Is There A Rural Differential? Columbia, MO: RUPRI Center for Rural Health Policy Analysis. Rural Policy Brief.2005;2010(02/07). Vol 10, No. 7 (PB2005-7). Available athttp://www.unmc.edu/ruprihealth/Pubs/PB2005-7.pdf.Accessed November 2, 2010. 3. American Hospital Association Resource Center. Fast facts on US hospitals. Updated November 11, 2009. Available athttp://www.aha.org/aha/resource-center/Statistics-and-Studies/fast-facts.html. Accessed February 7, 2010. 4. Stranges E, Holmquist L, Andrews RM. Inpatient stays in rural hospitals, 2007. Statistical Brief 85. Healthcare Costand Utilization Project (HCUP). Updated March 2010.Available at www.hcup-us.ahrq.gov/reports/statbriefs/sb85.jsp. Accessed March 30, 2010. 5. Coburn AF, MacKinney AC, McBride TD, Mueller KJ, Slifkin RT, Wakefield MK. Choosing Rural Definitions:Implications for Health Policy. Issue brief 2. 2007. 6. Hart LG, Larson EH, Lishner DM. Rural definitions for health policy and research. Am J Public Health . 2005;95(7): 1149-1155. 7. Mick SS, Morlock LL, Salkever D, et al. Strategic activity and financial performance of U.S. rural hospitals: a nationalstudy, 1983 to 1988. J Rural Health . 1994;10(3):150-167. 8. Mick SS, Morlock LL, Salkever D, et al. Horizontal and vertical integration-diversification in rural hospitals: a nationalstudy of strategic activity, 1983-1988. JRuralHealth .1993; 9(2):99-119. 9. US Census Bureau, Population Division. Metropolitan and micropolitan statistical areas. Updated March 23, 2010. Avail-able at http://www.census.gov/population/www/metroareas/metroarea.html. Accessed March 30, 2010. 10. Committee on the Future of Rural Health Care, Board on Health Care Services. Institute of Medicine of the National Academies. Quality Through Collaboration: The Future of Rural Health Care . Washington, DC: National Academies Press; 2004. 11. Kane RL, Shamliyan TA, Mueller C, Duval S, Wilt TJ. The association of registered nurse staffing levels and patientoutcomes: systematic review and meta-analysis. Med Care . 2007;45(12):1195-1204. 12. Skillman SM, Palazzo L, Keepnews D, Hart LG. Character- istics of registered nurses in rural versus urban areas:implications for strategies to alleviate nursing shortages inthe United States. J Rural Health . 2006;22(2):151-157. 13. Cramer M, Nienaber J, Helget P, Agrawal S. Comparative analysis of urban and rural nursing workforce shortages inNebraska hospitals. Policy Polit Nurs Pract . 2006;7(4):248-260. 14. Rural Assistance Center. CAH frequently asked questions. Updated October 26, 2010. Available at http://www.raconline.org/info_guides/hospitals/cahfaq.php#howmany. AccessedNovember 2, 2010. 15. Medicare Payment Advisory Commission (MedPac). Hos- pital inpatient and outpatient services: assessing paymentadequacy and updating payments. Updated 2004. Availableat http://www.medpac.gov/publications/congressional_reports/Mar03_Ch2A.pdf. Accessed February 8, 2010. 16. Dillman DA. Mail and Internet Surveys: The Tailored Design Method . 2nd ed. Hoboken, NJ: John Wiley & Sons, Inc; 2007. 17. Filip JC, Ming ME, Levy RM, Hoffstad OJ, Margolis DJ. Mail surveys can achieve high response rates in a dermatologypatient population. J Invest Dermatol . 2004;122(1):39-43. 18. Kramer M, Schmalenberg C. Development and evaluation of Essentials of Magnetism tool. J Nurs Adm . 2004;34(7-8): 365-378. 19. Newhouse RP. Exploring nursing issues in rural hospitals. J Nurs Adm . 2005;35(7-8):350-358. 20. Lake ET. Development of the practice environment scale of the Nursing Work Index. Res Nurs Health . 2002;25(3):176-188. 10.1002/nur.10032. 21. Gillies RR, Shortell SM, Anderson DA, Mitchell JB, Morgan KL. Conceptualizing and measuring integration: 136 JONA Vol. 41, No. 3 March 2011 Copyright @ 201 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. 1 findings from the health systems integration study. Hosp Health Serv Adm . 1993;38(4):467-489. 22. Newhouse RP, Morlock L, Pronovost P, Colantuoni E, Johantgen M. Rural hospital nursing: better environments =shared vision and quality/safety engagement. J Nurs Adm . 2009;39(4):189-195. 23. American Hospital Association. 2006 American Hospital Association Annual Survey. Updated 2010. Available athttp://www.aha.org/aha/resource-center/Statistics-and-Studies/data-and-directories.html. Accessed July 5, 2010. 24. Ballein Search Partners. Why senior nursing officers matter: a national survey of nurse executives. Updated 2003. Availableat http://www.aone.org/aone/docs/03sno_survey.pdf. AccessedFebruary 8, 2010. 25. The Joint Commission. Facts about critical access hospi- tal accreditation. Updated 2010. Available at http://www.jointcommission.org/AboutUs/ Fact_Sheets/cah_facts.htm. Accessed November 2, 1010. 26. Longo DR, Hewett JE, Ge B, Schubert S. Rural hospital patient safety systems implementation in two states. J Rural Health . 2007;23(3):189-197. 27. Chassin MR, Loeb JM, Schmaltz SP, Wachter RM. Accountability measures Vusing measurement to promote quality improvement. N Engl J Med . 2010;363(7):683-688. 28. Menachemi N, Chukmaitov A, Brown LS, Saunders C, Brooks RG. Quality of care in accredited and nonaccreditedambulatory surgical centers. Jt Comm J Qual Patient Saf . 2008;34(9):546-551. 29. Lichtman JH, Allen NB, Wang Y, Watanabe E, Jones SB, Goldstein LB. Stroke patient outcomes in US hospitals beforethe start of the Joint Commission Primary Stroke Centercertification program. Stroke . 2009;40(11):3574-3579. 30. Miller K. Urban/rural areas and CBSAs. Updated August 15, 2006. Available at http://www.rupri.org/Forms/WP2.pdf.Accessed March 30, 2010. 31. Aiken LH, Clarke SP, Cheung RB, Sloane DM, Silber JH. Educational levels of hospital nurses and surgical patientmortality. JAMA . 2003;290(12):1617-1623. 32. Drenkard K, Swartwout E. Effectiveness of a clinical ladder program. J Nurs Adm . 2005;35(11):502-506. 33. Moscovice I, Wholey DR, Klingner J, Knott A. Measuring rural hospital quality. J Rural Health . 2004;20(4):383-393. 34. Mazzocco K, Petitti DB, Fong KT, et al. Surgical team behav- iors and patient outcomes. Am J Surg . 2009;197(5):678-685. 35. Goldman LE, Dudley RA. United States rural hospital quality in the Hospital Compare database-accounting forhospital characteristics. Health Policy . 2008;87(1):112-127. 36. Jukkala AM, Henly SJ. Provider readiness for neonatal resuscitation in rural hospitals. J Obstet Gynecol Neonatal Nurs . 2009;38(4):443-452. JONA Vol. 41, No. 3 March 2011 137 Copyright @ 201 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. 1