Welcome to ACNL in Action, brought to you by the Association of California Nurse Leaders. I'm your host, Charlene Platon. Our guest today is Nika Ella Mariano, a nursing student at the University of San Francisco, who recently presented at ACNL's annual conference on strategies for revitalizing rural nursing. Nika Ella is here to talk about the current situation with rural nursing, why this topic is so important to our communities, and how we can improve things. Welcome, Nika. Thank you so much for being with us today. Thank you so much for having me. It's such a pleasure to meet you. You as well, and so excited to dive into your journey and very impressed with your recent presentation too at ACL. So I'm really excited to cover that a little bit more today, too. Thank you. And I think we'll start with some of your background in nursing. And I want to see if you could share a little bit about what inspired your interests in rural nursing and health equity.

Of course. Well, more than just a nursing student, I am a daughter, granddaughter, special needs caregiver, and aspiring student leader. But I'd say that intersected between all of these roles, I am a firm believer in the power of transformative change through advocacy, namely like uplifting the unheard. So being a Filipino American born and raised in the Bay Area, I acknowledge how much of a privilege it is to pursue a private education in the heart of an urban metropolitan center. But it's with the same privilege that I recognize we have a power to extend the resources that we do have towards communities in need, and that the care we learn about in the school and aspire to provide should not be limited to the confines of the environments we live in. And I think I got best involved with nursing in a rural context, not only through my involvement with the AECN Student Policy Summit, but even by working firsthand in a local midwifery clinic in rural Philippines, because it's shown me how other countries, cultures, and environments utilize the resources they do have in ways that the US can very much learn from. And I think that's why one of the key factors driving my interest in nursing research and finding answers to otherwise unanswered questions is to seek transformative change rooted in a sense of community, even beyond the Bay Area and where I may directly live, and to areas beyond our field of sight.

That's so powerful, Nika. And your story really resonates with me as well. I'm also a Filipino-American nurse and also born and raised in California, but I think it's so special that you have this uh focus and passion on, you know, supporting rural nursing and health equity. And I'm wondering if there's a certain experience during either your education or your clinical training or experience that really sparked this interest or really inspired your project.

Oh, okay. I I'd say though, one thing I love the most about being a student at USF is how much our school champions the model of community-engaged experiential learning. So I'm very grateful that the support of our dean, Eileen Freibowers, and our School of Nursing Director of Partnerships, Ms. Carolina Ekaveria, because they both supported me in this opportunity to advocate for nursing education improvements at Capitol Hill. We were able to advocate for the FAN Act as well as the Title VII nursing grants because they helped me inspire, they helped inspire me in researching tactics to convince legislators why it's important to invest in nursing from an educational standpoint. There's this one bill, the Title VIII Nursing Workforce Workforce Reauthorization Act, that strives to increase loan repayments, scholarships, and grants that can help support nurses and students, specifically by linking them to underserved communities. And while I was trying to explore ways to convince our legislators, I wanted to get first hand experience from our own class and our own peers. So when I was serving as our class's cohort representative, that gave me a unique insight into seeking firsthand the extended career goals that my own classmates had when thinking post-grad. In the same light, I was deeply inspired by the work of our fellow USF educators and nurse leaders. We have Dr. Joe Loomis and Dr. Alexa Curtis. Much of their work specializes not only in nursing education and simulations, but with a special focus on remote nursing and underserved rural populations. For example, Dr. Curtis had specialized in a medication assistant treatment center, so it's called a MAT center in a rural community. And even Dr. Loomis developed a poverty simulation, which I was a part of the pilot cohort to experience it for us as BSN students to integrate community nursing into our nursing education. So I think with all of these combined, I'm really centered around how can I analyze how our current school community understands rural healthcare, what can we do to improve outcomes for it, and how can we share that with schools beyond our San Francisco?

That's great, Nika. Thank you for sharing that. And it's so interesting to hear about the different opportunities that USF was able to provide during your nursing education. And you mentioned about community nursing, and it sounds like was that already embedded into the curriculum for your program? Just having those experiences in community?

We do have one part of our curriculum being our junior one semester, where we are involved with psychiatric, behavioral health, and community health nursing. But I'd say that having that poverty simulation being a simulation that is not only focused on the clinical, but more the social determinants of health, was a very unique experience that I'm glad that they are continuing to provide and pilot because it helps students understand that health is not confined to the walls of a hospital or to the facility or clinic, but rather it is involved in the ways that people live their lives even outside the hospital. So I'd say that now that we're trying to improve our focus on community health nursing, it's continued to inspire me and see what more can we do to improve the outcomes for future students.

That's wonderful. And such a powerful tool to embed into your education, right? To have a simulation. Because I mean, when we talk about simulations, we always talk about clinical simulations, right? Like maybe a code blue or something similar. But we might not have the same simulation or exposure for a community type of setting and a community type, a real really realistic scenario like what you described. Yes, that's true. And I, you know, it's it's really great to hear about how all these different experiences shapes your your actual interests in research. And and speaking about more about your research, you know, I know that it's looking into how current pre-licensure nursing education can influence postgraduate career goals, especially when we talk about rural career pathways. And what were you hoping to discover most with this research?

I feel like we as students are often tasked with the question, the inevitable questions in every conversation, such as what specialty are you interested in? Or what do you want to work postgrad? And I personally wanted to analyze how possibly our environmental context, being raised in San Francisco, surrounded by metropolitan hospitals, magnet hospitals, and the environmental context of our curriculum and training, may have directly or even discreetly influenced our career goals. One thing I noticed in conversations with my own classmates is how many times when our teacher asks us, is anyone interested in working in a clinic after graduation or working in, like, let's say, less mentioned specialties such as wound care, et cetera, not many students raise their hand, not because they don't want that right away, but many students admit that they are not exposed to training that might um directly prepare or contextualize what it means to be in that situation. So, for example, while remote and rural health specializations can be offered as pathways in advanced practice RN programs like NPs, oftentimes undergraduate level nursing programs tend to focus on bedside hospital-centered care. We like to joke, like you were mentioning, in our simulation lab or when we're studying for our exams, many of our interventions and our nursing judgment is based around an ideal, well-stocked, NCLEX style hospital where we have adequate staffing and supplies. But needless to say, that's not true or realistic for many US care facilities. And we want to help prepare students to be ready and equipped to have the mindset to adapt even when they're in a situation that they might not have all the resources they expect. And it's for this reason that I wanted to uncover factors that might not only influence postgrad um goals, but can help improve what improve the curriculum we do have to better equip them for any situation.

Yes, and there are a few things I want to touch upon, what you just shared, because there's so many interesting nuggets there. And the first is how interesting it is that we really can be highly influenced by our surroundings, by what we see, even by how our education is organized and the exposures that we have there. And very interesting to hear that when interviewing some of your peers, they mentioned that they wouldn't necessarily, you know, I guess consider a clinic as one of their first or their primary um nursing roles or or facilities where they would want to start their career. And I'm curious when you were interviewing other students or, you know, serving students, were there other interview responses that stood out as well?

Oh, yes. I would say that at least based on those who I've been able to speak with, I understand that I want to continue expanding this um survey, possibly to other schools outstate. I want to see how they compare not only to California, but I noticed that a majority, I believe 67% of the respondents I interviewed claim that they believe that their nursing school might not necessarily prepare them for a long-term career in rural or remote region. But 40% of those students expressed that they would be interested, genuinely interested, in serving an underserved rural population if they had the experience formally integrated into the required clinical placements. But there are a number of factors and barriers that may influence whether they want to pursue such clinical placements, that being distance, time, um, a lot of untapped biases that I've noticed regarding misconceptions around rural nursing, what it means to work in an environment like that, because these are things that we may be able to learn about in textbooks or in lectures. But until we're fully in those shoes, even myself, until I went to the Philippines and saw it myself, that does not compare exactly to what it would mean to work in a California or United States rural nursing environment. So I keep an open mind understanding that when planning a potential simulation or seeing what it means to work in such a place, that the best experience comes through immersion. But I I do keep in mind that these results can change over time. And with this information, I want to see like what interventions can we implement to potentially change the course of these results for future generations.

Yes, and that is so interesting too, because it really speaks to the earlier topic of the influence, right? About what we're exposed to and what we are familiar with. And a lot of it stems from our starting point in nursing school, right? Or our experiences in nursing school. So if your nursing school does not offer clinics in rural settings, we probably won't be as interested in diving into it because we just might not know it exists as an option, right? And then likewise, because many schools offer inpatient uh experiences for clinicals, that's what a lot of nurses tend to start with, if I'm understanding correctly.

I believe that's true. And I noticed that it focuses on that for undergraduate or pre-licensured students, but advanced practice nurses have every opportunity, or not every opportunity. I would say like rural healthcare is offered as a specialty for advanced practice nurses. And I'm very thankful for that because USF offers that as well. But I wanted to see how we can extend that to PSN students, how can we see what BSN students can extend their um their lexicon to that sense?

And that's a really good point, too. I am also a family nurse practitioner by background, and many of the clinical rotations in the NP program were focused on federally qualified health centers or FQHCs. And many of those facilities and clinics, as you know, are in more of the communities that are underserved, or maybe the patients are more have a tendency to be more underinsured and need some more of that support from the community, you know, just from a community perspective. So it is really interesting to think about the fact that there are a lot of advanced practice nurses that have those exposures, but that doesn't always translate to our undergrad students who might actually want to start a career in ambulatory care, right, versus maybe in an inpatient setting. So very, very interesting. And I wanted to talk about the next point that you mentioned too about interventions, right, to help with some of these experiences. And from what I understand, you're working on an immersive simulation experience for nursing students to train in rural health care scenarios. And I'm so excited to learn more about that. And can you talk about how that's going?

Yes. Well, I will admit that it is still a work in progress. But what keeps me going is the potential that immersive, community-tailored experiential learning can have on shaping the same sorts of students that had one surveyed in the past and gotten those results from? So if we are able to integrate simulations such as our poverty simulation, which helps us contextualize, for example, um the same people that we see outside our doorstep in San Francisco or even those in other areas, how can we possibly create a realistic, sustainable simulation experience rooted in community experiences that are that are unique to rural healthcare communities across the United States? And that would mean making sure that we understand the social determinants of health from a firsthand perspective and not necessarily based or rooted in the assumptions or biases we may have around them. One, I'm deeply inspired by Dr. Joe Loomis's mission and how she developed an interprofessional educational clinical experiences for her NP students. And she immerses them directly into rural communities such as schools and clinics within the California Central Valley. And while, of course, we may pay mind to resources and how this was made possible by HERSA grants, I would love to extend such communities to BSN students, possibly developing clinical placement opportunities for capstones for undergraduate students to pursue abroad, or we can even have these certain concentrations or pathways that BSN students can pursue should they be interested in ambulatory care in underserved communities. These are still ongoing conversations. I'm continuing to have with Miss Ekiberia and Dean Leen Fry Bowers, but it is with this in mind that these ideas are at least put out there to see what interventions can be implemented to expose students to the rural healthcare situations that they may have questions on while still paying mind to making it accessible and sustainable resource-wise.

Well, thank you for sharing that. And I really want to commend your work on this and really stepping into this landscape because this is a very unique uh opportunity. And having something like this immersive simulation experience for nursing students in a community setting that is a rural setting would be incredibly beneficial and so unique, honestly, for those programs where those nurses can participate and learn about that. And so I just want to say congratulations for for starting that progress and taking that first step because that takes a lot of work to do. And I do want to actually focus a little bit too on rural nursing and you know, zooming out a little bit, um, you mentioned earlier about um when it comes to rural nursing, there can often be some misconceptions about what rural nursing is or what rural health care is. And I'm curious if you could, you know, talk a little bit more about what do you think most people misunderstand when it comes to rural health care?

I think that many people tend to misinterpret remote area nursing as being very isolating and stressful. When in reality, the National Rural Health Association says that working in such a tight-knit community can actually be a very fulfilling experience for many nurses who've been surveyed in the past. Though there are a few challenges in attracting and retaining them. For example, the understaffing and lack of resources can lead to burnout and compromise patient care. And this scares a lot of people who may not be familiar with rural hospitals and um what it means to work in one. So people tend to misinterpret the lack of autonomy or the lack of resources as being a very prone to burnout environment. But one thing that many of our students who are interested in becoming advanced practice RNs may not realize is the untapped potential they can have in working in a rural community. For example, Assembly Bill 890 is one that grants advanced practice nurses further autonomy and helps expand their clinical capabilities as a primary care provider. And many don't realize that this can be made possible for those who choose to work in clinics. They can have the same clinical judgment as, let's say, a doctor would have and be able to thus extend and utilize their skills more broadly, caring for patients in ways that they don't necessarily have to rely on a primary care provider to give them orders or et cetera. So for many who are interested in pursuing graduate level nursing, this can be a wonderful opportunity for them to extend beyond what would be otherwise possible in an urban setting.

Yes, and there were a lot of great points that you had there. I do agree completely that there are a lot of those misconceptions about what rural healthcare will entail and that it could lead to a potentially high-intensity, high burnout type of setting. I am curious if you have any thoughts as to where these misconceptions come from.

I feel like perhaps, at least for the context of those who have been able to survey, the lack of exposure to these clinical areas can be a huge factor because it's based on what we are able to observe and hear about the current state of rural nursing. For example, understanding that over 100 rural hospitals have closed just between 2013 and 2020 alone, that is a huge factor that has been not only negatively impacting patient-centered care, but also affecting the staff retention and the attractability of working in rural health care situations. So I think for those students who have yet to experience firsthand what it means to work in such an area, um, many of these misconceptions come from what we're able to hear or see about it, but our best experience when um directly up front.

Yes, and that makes a lot of sense, right? That, you know, that the lack of the exposure to these settings would really shape what we may or may not know about those settings, you know, unless we grew up in those settings or had some direct exposure to it in other ways outside of nursing school. And um, I did want to also, you know, piggyback on what you said earlier about how these experiences, you know, it is unfortunate that there are those misconceptions because if it is pervasive, it could influence someone from not going into those settings. But um by going Into those settings, nurses really can uh influence their path, especially if they do want to become an advanced practice nurse. And it could really set them up for a lot of success. I mean, really not only limited to advanced practice nursing, but even in their other types of nursing careers, because there's so much that you could do with this additional exposure and information that is not typically offered. There's so much opportunity, which is actually really much underscored by how you mentioned that many rural facilities and hospitals are closing. There's even more opportunity there to make an impact. And I was curious, you know, with all of that said, what do you think are really the biggest challenges when it comes to attracting and retaining nurses who are in these areas? Because, you know, maybe they've already invested and they're in these areas now, but what would be the hardest um parts about retaining the nurses who are already working in these areas?

I think that as mentioned earlier, um having like the understaffing and the lack of resources, um, that can be a frustrating experience for nurses who are trying to provide the best possible care for their patients. For example, if a clinic or a local community hospital lacks the advanced diagnostic equipment or any of the specialized medical services which are necessary for processing test results or advanced procedures, care can be delayed while you're waiting for such results or such transfers to be performed at an outside facility. So if we are able to invest in helping supply these um remote healthcare facilities with the equipment and supplies that they need, that can greatly help improve the outcomes not only of patients, but also the retention of staff, because it can help them be able to perform their job well and extend their care to those who need it most. I also noticed that according to the National Rural Health Association, another factor that tends to be a barrier for nurses in entering rural nursing is the lack of professional or educational advancement opportunities, especially when they want to care for complex patients. It tends to be that with a limited scope or limited resources, nurses can grow frustrated with the scope of care that they're able to provide, unless, of course, they're able to pursue such advanced nursing degrees. But um it is with this, with the need for adaptability and um extended care that these nurses are striving to have more opportunities to expand their capacity for care. And this can be best done if we are able to implement more training programs or more advancement opportunities for them to pursue. And of course, the another unspoken yet um widely understood barrier is the pay, because many nurses want hospitals to invest in competitive wages for their long-term employees. Um, understandably, PRN nurses who work in rural healthcare tend to have like inviting or incentivizing uh pay grades that they are able to um pursue whenever they're whenever they're offered. But for those who are pursuing permanent positions in um rural nursing facilities, it is important that we have competitive wages for long-term employees because it's not that there's a shortage in nurse availability, but there's a shortage in um retention and stability in that sense. Should communities invest in paying their permanent staff more, we would be able to help incentivize long-term retention for nurses in community nurse settings.

Yes, and you raise a lot of uh really valid points here because, you know, if we're looking at retaining nurses in these areas, all of those points that you mentioned are going to be really important to keep the nurses, you know, not only to attract them, but to keep them. And having incentives for longer-term nursing roles and positions would really impact those decisions, right? For nurses who choose to stay or who choose to leave, just like other other any other nursing role, right? And I was also wanting to touch upon the education piece, you know, speaking to what you mentioned, because if we are going to look to have more nurses in these um different settings, what would an ideal rural nursing education program actually look like from your perspective in terms of the structure and clinical placements?

I believe that such a system can be twofold. So for a rural nursing education program to best not only supplement the nurses who are involved, but also the outcomes of the patients, I believe that we can help link and facilitate those connections between urban and suburban um nursing education programs and rural health communities in need. Urban universities can facilitate clinical placements in rural healthcare settings, should they be able to facilitate those connections with the rural health care um systems. But also in the same sense, rural communities with lack of access to certain educational opportunities, if the if the government is able to invest in providing nursing education programs for rural residents to pursue nursing on their own, which is already rare, that can help sustain stable nursing, stable nursing workforce from within. So it's not only are people able to come into those rural communities where help is needed most, but they will be able to help be self-sustaining should they be provided with the educational and professional advancement opportunities that they need. Of course, if we're to extend from rural from urban to rural communities, that would require some time and um funding for, let's say, travel and housing for especially those who don't already live in rural communities. But it is through these grants and scholarship opportunities like those provided by HERSA, or even those that are advocated by the Title VII grants, that we can help facilitate those connections and make it sustainable and rewarding for those people to earn the training that they need while still serving those who need service the most.

Yes, I think that with all those components that you mentioned, you know, nursing education could really benefit from having those that such a program in place. And it could really open the eyes of many nurses who are students and who are looking to learn more about those communities, and then even impact how those communities are able to have a, you know, a better pathway for making those placements happen. And then as a result from that, even maybe even more job opportunities. So I think that's so valuable to have that mindset for what one of those programs could look like. And I I feel that, you know, this is such an important topic, and there's so much to talk about here. Um, but in wrapping up our conversation for today, I do want to invite um the opportunity for you to share any final words of or um any final wisdom that you'd want to share with our listeners today.

Of course. First of all, I'm very grateful for the opportunity to not only pursue nursing as a health-centered profession, but also to be surrounded by incredible nurse leaders such as those with the ACNL. And I recognize that it's a privilege which I hope to continue paying forward for those who need it most. And by striving to sustainably support underserved communities, I hope that it can help inspire future students or aspiring nurse leaders to see beyond their field of sight and see where we can help dedicate the resources we do have or the thoughts and questions that may go unanswered towards research that can help change the future of tomorrow. So I'm very thankful for the mentorship and the support of not only my mentors in my university, but also my extended community for helping me be a healing presence.

Wonderful. Well, thank you so much for all the work that you do to support this population, Nika, and thank you for being here with us today. Thank you so much. Our guest today was Nika Ella Mariano, student nurse at the University of San Francisco. We would love to hear your feedback. Email us at socialmedia at acnl.org and connect with us on LinkedIn and Facebook at ACNLNurse. And as always, if you like the show, please remember to rate, review, and share. ACNL in Action is presented by the Association of California Nurse Leaders with new episodes on the first Friday of every month. To learn more about the show or ACNL in general, visit us at ACNL.org. Thank you for listening.