NURS 8114 Week 2 Discussion: EXPLORING MIDDLE RANGE THEORIES AND FRAMING PRACTICE ISSUES

Walden University NURS 8114 Week 2 Discussion: EXPLORING MIDDLE RANGE THEORIES AND FRAMING PRACTICE ISSUES– Step-By-Step Guide

This guide will demonstrate how to complete the Walden University NURS 8114 Week 2 Discussion: EXPLORING MIDDLE RANGE THEORIES AND FRAMING PRACTICE ISSUES assignment based on general principles of academic writing. Here, we will show you the A, B, Cs of completing an academic paper, irrespective of the instructions. After guiding you through what to do, the guide will leave one or two sample essays at the end to highlight the various sections discussed below.

How to Research and Prepare for NURS 8114 Week 2 Discussion: EXPLORING MIDDLE RANGE THEORIES AND FRAMING PRACTICE ISSUES

Whether one passes or fails an academic assignment such as the Walden University NURS 8114 Week 2 Discussion: EXPLORING MIDDLE RANGE THEORIES AND FRAMING PRACTICE ISSUES depends on the preparation done beforehand. The first thing to do once you receive an assignment is to quickly skim through the requirements. Once that is done, start going through the instructions one by one to clearly understand what the instructor wants. The most important thing here is to understand the required format—whether it is APA, MLA, Chicago, etc.

After understanding the requirements of the paper, the next phase is to gather relevant materials. The first place to start the research process is the weekly resources. Go through the resources provided in the instructions to determine which ones fit the assignment. After reviewing the provided resources, use the university library to search for additional resources. After gathering sufficient and necessary resources, you are now ready to start drafting your paper.

How to Write the Introduction for NURS 8114 Week 2 Discussion: EXPLORING MIDDLE RANGE THEORIES AND FRAMING PRACTICE ISSUES

The introduction for the Walden University NURS 8114 Week 2 Discussion: EXPLORING MIDDLE RANGE THEORIES AND FRAMING PRACTICE ISSUES is where you tell the instructor what your paper will encompass. In three to four statements, highlight the important points that will form the basis of your paper. Here, you can include statistics to show the importance of the topic you will be discussing. At the end of the introduction, write a clear purpose statement outlining what exactly will be contained in the paper. This statement will start with “The purpose of this paper…” and then proceed to outline the various sections of the instructions.

How to Write the Body for NURS 8114 Week 2 Discussion: EXPLORING MIDDLE RANGE THEORIES AND FRAMING PRACTICE ISSUES

After the introduction, move into the main part of the NURS 8114 Week 2 Discussion: EXPLORING MIDDLE RANGE THEORIES AND FRAMING PRACTICE ISSUES assignment, which is the body. Given that the paper you will be writing is not experimental, the way you organize the headings and subheadings of your paper is critically important. In some cases, you might have to use more subheadings to properly organize the assignment. The organization will depend on the rubric provided. Carefully examine the rubric, as it will contain all the detailed requirements of the assignment. Sometimes, the rubric will have information that the normal instructions lack.

Another important factor to consider at this point is how to do citations. In-text citations are fundamental as they support the arguments and points you make in the paper. At this point, the resources gathered at the beginning will come in handy. Integrating the ideas of the authors with your own will ensure that you produce a comprehensive paper. Also, follow the given citation format. In most cases, APA 7 is the preferred format for nursing assignments.

How to Write the Conclusion for NURS 8114 Week 2 Discussion: EXPLORING MIDDLE RANGE THEORIES AND FRAMING PRACTICE ISSUES

After completing the main sections, write the conclusion of your paper. The conclusion is a summary of the main points you made in your paper. However, you need to rewrite the points and not simply copy and paste them. By restating the points from each subheading, you will provide a nuanced overview of the assignment to the reader.

How to Format the References List for NURS 8114 Week 2 Discussion: EXPLORING MIDDLE RANGE THEORIES AND FRAMING PRACTICE ISSUES

The very last part of your paper involves listing the sources used in your paper. These sources should be listed in alphabetical order and double-spaced. Additionally, use a hanging indent for each source that appears in this list. Lastly, only the sources cited within the body of the paper should appear here.

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SAMPLE RESPONSE 1 FOR NURS 8114 Week 2 Discussion: EXPLORING MIDDLE RANGE THEORIES AND FRAMING PRACTICE ISSUES

Nursing theories offer the essential knowledge of care principles that guide and explain the practices and decisions of experts in the field for the benefit of patients to improve their health and well-being (Younas & Quennell, 2019).  I have worked in an inpatient psychiatric unit for over ten years, caring for patients with diverse mental health conditions. One of our challenges is the frequent readmission of patients after discharge. According to Owusu et al. (2022), the deinstitutionalization has led to a more significant and faster transition from inpatient psychiatric care to treatment in the community, and many patients have had severe problems after being discharged from psychiatric hospitals, which increased the number of psychiatric emergency readmissions to the acute wards. The increase in readmission has posed a significant challenge in psychiatry. The greater the number of readmissions, the greater the pressure on hospital psychiatric units and their limited resources. 

Most patients seeking re-hospitalization cite poor medication adherence as the main reason. Compliance with medication is essential but challenging in managing major psychiatric disorders. Proper medication use by patients is one of the most critical factors contributing to better outcomes and decreased utilization. Patients not adherent to their medication regimens have a poorer prognosis than adherent patients. Of all medication-related hospitalizations in the USA, 33%–69% result from medication non-adherence (Rosen et al., 2017). Patients with major psychiatric disorders are most likely to be non-adherent to medication due to poor reasoning and lack of insight about their illness and treatment. Psychotropic medication non-adherence can exacerbate their illness, reduce treatment effectiveness, or leave them less responsive to subsequent treatment. Other consequences of non-adherence include re-hospitalization, poor quality of life or psycho-social outcomes, relapse of symptoms, increased co-morbid medical conditions, wastage of healthcare resources, and increased suicide (Semahegn et al., 2020). Nursing research forms the basis of middle-range nursing theories, which apply to everyday nursing practice (McEdwin & Willis, 2019). Several nursing theories can guide healthcare professionals to implement strategies to increase medication adherence, decrease relapse in symptoms, promote the well-being of patients suffering from psychiatric disorders, and decrease the rate of hospital readmissions after discharge.  

Middle range theories  

Finfgeld-Connet conceptual model of social support 

Finfgeld-Connet conceptual model of social support defines social support as an advocative interpersonal process that involves emotional, instrumental, structural, and functional supports to improve mental health (McEwan & Wills, 2021). The model proposes that social support will help enhance coping and resilience, reduce stress and psychological distress, increase self-esteem and self-efficacy, and improve quality of life. The model suggests that nurses can facilitate social support for their patients by assessing their needs and preferences, providing emotional and informational support, helping them access resources and services, encouraging them to seek or maintain supportive relationships, and evaluating the outcomes of social support interventions. 

Patients with psychiatric disorders often lack support from family, friends, or caregivers who can provide emotional, practical, or financial assistance. This lack of support increases stress, isolation, and vulnerability. In addition, they don’t have effective aftercare upon discharge from the hospital and lack quality community-based mental health services that can provide continuity of care, crisis intervention, or rehabilitation. This can result in unmet needs and gaps in care.  Adequate and effective inpatient treatment and well-coordinated psychological care and medication management after discharge are crucial to enhancing medication compliance and reducing the risk of readmission. Ensuring that patients have the delivery of sufficient support services to transition psychiatric care successfully from an inpatient to an outpatient setting is essential. For example, offering discharge services, follow-up calls, short-term case management, peer support, and psychoeducation to support patients after discharge can increase compliance with treatment and reduce readmission (Owusu et al., 2022). 

Health Belief Model 

The Health Belief Model (HBM) evaluates and predicts health-related behaviors and helps explain or mediate the effects of demographic factors on health behavior patterns, which are amenable to change through health education. The HBM focuses on risk perception, assessed by an individual’s perceived susceptibility to disease and disease severity, and on behavioral evaluation, which is determined by the individual’s perceived benefits and barriers to adopting healthy behavior. The model also includes cues to action, individuals’ health motivations to adopt healthy behavior, and self-efficacy to perform the required behavior (Alagili & Bamashmous, 2021). The Health Belief Model can help identify what factors might encourage or inhibit an individual from utilizing mental health services. This socio-cognitive model proposes that people are likely to engage in a given health-related behavior when they believe the problem could have severe consequences for daily living activities when they believe the intervention will be effective, and when they perceive few barriers to taking action. Patients with mental health disorders often lack insight into their conditions and stop taking their medications without consulting healthcare providers. This can lead to worse outcomes, such as recurrence of symptoms and hospital admission.

 Healthcare professionals can use the Health Belief Model to assess patients’ beliefs and attitudes about their illnesses and the recommended actions. Also, they can provide information and education to increase the patient’s awareness and knowledge of their diseases and actions. Some patients stop taking their medications due to concerns about side effects. For example, some patients might become overweight or present with an even more severe metabolic syndrome, and other patients might feel drowsy and unable to function during the day, which leads them to believe that the medication is harmful to them and not appreciate the medications’ effectiveness. It is essential to provide better education about side effects and the importance of adherence to sustain the benefits of medication. This education should encourage patients to discuss their symptoms and side effects with their providers rather than stop taking medication.  

Nursing theories offer essential knowledge that helps guide and define nursing care and provide a foundation for clinical decision-making. Nursing theories can help nurses identify the goals and outcomes of nursing care, apply evidence-based knowledge and skills to practice, evaluate the effectiveness and quality of nursing care, and advocate for the health and well-being of individuals, communities, and populations.  

References 

Alagili, D. E., & Bamashmous, M. (2021). The Health Belief Model as an explanatory framework for COVID-19 prevention practices. Journal of infection and public health, 14(10), 1398–1403. https://doi.org/10.1016/j.jiph.2021.08.024 

McEwen, M., & Wills, E. M. (2019). Theoretical basis for nursing (5th ed.). Wolters Kluwer. 

Owusu, E., Oluwasina, F., Nkire, N., Lawal, M. A., & Agyapong, V. I. O. (2022). Readmission of Patients to Acute Psychiatric Hospitals: Influential Factors and Interventions to Reduce Psychiatric Readmission Rates. Healthcare (Basel, Switzerland), 10(9), 1808. https://doi.org/10.3390/healthcare10091808Links to an external site. 

Rosen, O. Z., Fridman, R., Rosen, B. T., Shane, R., & Pevnick, J. M. (2017). Medication adherence as a predictor of 30-day hospital readmissions. Patient preference and adherence, 11, 801–810. https://doi.org/10.2147/PPA.S125672Links to an external site. 

Semahegn, A., Torpey, K., Manu, A., Assefa, N., Tesfaye, G., & Ankomah, A. (2020). Psychotropic medication non-adherence and its associated factors among patients with major psychiatric disorders: A systematic review and meta-analysis. Systematic Reviews, 9(1). https://doi.org/10.1186/s13643-020-1274-3Links to an external site. 

Younas, A., & Quennell, S. (2019). Usefulness of nursing theory‐guided practice: An integrative review. Scandinavian Journal of Caring Sciences, 33(3), 540–555. https://doi.org/10.1111/scs.12670Links to an external site. 

SAMPLE RESPONSE 2 FOR NURS 8114 Week 2 Discussion: EXPLORING MIDDLE RANGE THEORIES AND FRAMING PRACTICE ISSUES

Providing adequate care to patients with advanced illnesses requiring palliative or end-of-life care is one of the practice issues faced by practitioners. This type of care prevents and relieves suffering through the early identification, correct assessment and treatment of pain and other problems, whether physical, psychosocial or spiritual. Managing pain, addressing emotional needs, and supporting families during these difficult times can be emotionally demanding (Coelho et al., 2016). Practitioners deliver comprehensive palliative care, focusing on symptom management, improving quality of life, and addressing patient’s physical, emotional, social, and spiritual needs (Blakeman, 2019). They also collaborate with interdisciplinary teams to provide holistic, patient-centered care and ensure continuity of care by coordinating transitions between different healthcare settings.

The Theory of Unpleasant Symptoms provides an excellent palliative care symptom management framework. This model recognizes that symptoms experienced by individuals are complex and influenced by physiological, psychological, and situational factors (Mcewen & Wills, 2019). In palliative care, where symptom control and quality of life are essential, this theory helps healthcare professionals assess and manage symptoms effectively. Patients in palliative care may experience sensory-perceptual symptoms, such as pain and fatigue, neuropsychological symptoms, like anxiety and depression, and behavioral responses affected by symptoms (Blakeman, 2019). Attention to situational factors, such as the healthcare environment and communication, improves symptom management (Blakeman, 2019). Finally, focusing on symptom outcomes helps set realistic goals to enhance the quality of life. By applying this theory, palliative care teams can comprehensively address the multi-dimensional nature of symptoms, improve patient well-being, and optimize their overall care experience.

Kolcaba’s Theory of Comfort is also applicable to enhance palliative care. This theory seeks to define comfort within nursing practice and promote health-seeking behaviors by addressing the comfort needs of patients and their families (Mcewen & Wills, 2019). In palliative care, this theory guides nurses in promoting comfort through various means. Physically, it encourages the effective management of symptoms such as pain, dyspnea, and fatigue using evidence-based interventions. Psychospiritual comfort is addressed by attending to emotional needs, facilitating open communication, and providing spiritual support based on individual beliefs (Coelho, et al., 2016). Social comfort is upheld by respecting cultural practices and beliefs, promoting inclusivity, and addressing social concerns. Lastly, environmental comfort is achieved by optimizing the physical environment to provide privacy, incorporate familiar objects, enhance safety, and address sensory stimulation based on the patient’s preferences (Coelho et al., 2016).

  References

Blakeman, J. R. (2019). An integrative review of the theory of unpleasant symptoms. Journal of Advanced Nursing, 75(5), 946–961. https://doi.org/10.1111/jan.13906

Coelho, A., Parola, V., Escobar-Bravo, M., & Apóstolo, J. (2016). Comfort experience in palliative care: a phenomenological study. BMC Palliative Care, 15(1). https://doi.org/10.1186/s12904-016-0145-0

Mcewen, M., & Wills, E. M. (2019). Theoretical basis for nursing (5th ed.). Wolters Kluwer.

SAMPLE RESPONSE 3 FOR NURS 8114 Week 2 Discussion: EXPLORING MIDDLE RANGE THEORIES AND FRAMING PRACTICE ISSUES

When faced with ill health and seeking medical attention, a patient’s greatest need is to receive quality care. Therefore, nurses’ responsibility is to ensure effective communication with patients, delivering essential elements of respect, teamwork, a supportive environment, and compassion, respectful, and dignified care according to the healthcare quality framework (Cusack et al., 2023, p.47). One of the leading nursing practice issues affecting the quality of care is the global nursing shortage which poses a real ethical nursing challenge in providing good quality care in the current environment (Vinckx et al., 2018). Working both as a staff nurse and as a travel nurse in virtually all the hospitals and healthcare facilities I worked in, the primary issue management always struggled with was short staffing, and this tremendously affected the nurse’s performance at work. Some of the consequences of short-staffing result in nurses being overloaded and working under so much pressure, thereby affecting quality nursing care (Vinckx et al., 2018).

Middle-range nursing theories

Middle-range theories were created to resolve the nursing practice issue and are related ideas focused on a limited dimension of the reality of nursing (Smith et al., 2023). One of the theories about good quality care and nursing shortage is the Jean Watson theory of respect and human intelligence, and the second theory to resolve nursing shortage and improving quality patient care is the systems theory. The reason for choosing these theories is that they are intertwined, correlated, and complement each other. In the first theory, Jean Watson’s theory of care and human intelligence, he states that the essential qualities the nursing staff should have to carry out their daily work are self-control, enthusiasm, self-motivation, and empathy which facilitates the aligning emotional resources that promote more extraordinary ability in solving problems, in promoting harmonious interpersonal relationships, thus increasing social skills, which helps to enhance work performance and generate defenses for a positive reaction to tension and stress (Jean Watson, 2015). While these nursing qualities stem from within and positively impact nursing care, if the system is broken or has flaws, it may still pose a problem in resolving good patient care at the level of the nurse. Therefore the systems theory is the second theory of choice to resolve the issue. The systems theory involves how things are structured from above in an organization to influence outcomes (Pan, 2022). How a healthcare facility, institution, or organization is structured will significantly enhance patient care. The problem which was raised affecting nursing care is short staffing, this can only be resolved by management, and it is a systemic and organizational problem which, despite the nurse’s ethical responsibility to provide the best care for their patients, may not be able to satisfy it to the fullest as a result of burnout like during the COVID 19 pandemic years (Beier et al., 2023, p. 47). 

In summary, nurses have a significant role in providing adequate patient care, which could be innate qualities or learned. Still, the health care facility must provide a conducive environment for their nurses to work while minimizing stress to perform their duties with passion by recruiting more nurses and encouraging a team spirit so that patients, on leaving the hospital, are satisfied with their care.

References

Cusack, L., Thornton, K., & Brytan, J. (2023). Exploring responsibilities for delivering quality nursing care using the healthcare quality framework. Collegian, 30(1), 47-52. https://doi.org/10.1016/j.colegn.2022.07.004Links to an external site.

Vinckx, M., Bossuyt, I., & Dierckx de Casterlé, B. (2018). Understanding the complexity of working under time pressure in oncology nursing: A grounded theory study. International Journal of Nursing Studies, 87, 60-68. https://doi.org/10.1016/j.ijnurstu.2018.07.010Links to an external site.

Machín, E. I. (2015). Enfermería: Teoría de Jean Watson y la inteligencia emocional, una visión humana. Revista Cubana de Enfermería, 31(3), 1.

Pan, Y. (2022). The Curriculum Knowledge Analysis of Marxist Philosophy and System Theory Based on Association Rules. Computational Intelligence and Neuroscience, 2022, 4543851. https://doi.org/10.1155/2022/4543851Links to an external site.

Beier, M. E., Cockerham, M., Branson, S., & Boss, L. (2023). Aging and burnout for nurses in an acute care setting: The first wave of COVID-19. International Journal of Environmental Research and Public Health, 20(8), 5565. https://doi.org/10.3390/ijerph20085565Links to an external site.

Smith, M. J., Liehr, P. R., & Roger D. Carpenter, N. (2023). Middle range theory for nursing. Springer Publishing Company.

SAMPLE RESPONSE 4 FOR NURS 8114 Week 2 Discussion: EXPLORING MIDDLE RANGE THEORIES AND FRAMING PRACTICE ISSUES

All of us are nurses, but nurses that work in the hospital with direct patient care are a special breed. I worked on medical surgical unit for about 15 years. I started in 2003 and left the floor in 2017. When I was in nursing school i loathed medical-surgical class. As a new nurse I think ALL nurses need to do a two-year orientation on medical-surgical unit. This is a great building block. One of the hardest things to do is work on the floor being short-staffed. Doesn’t matter what role (secretary, CNA, patient care technician, LPN, RN, housekeeping, staff that delivers meal trays). Taking care of patient is not a one-person job, it takes a team. The two theories are great, Jean Watson theory of respect and human intelligence and the systems’ theory.

Swansons’ theory of caring is a great middle range theory for your topic. Caring is the driving force of all nurses. I feel that is the main difference between nurse practitioners and physicians assistants, caring that is imbedded in nurses. As laid out by Moffa (2015) Swanson the five processes of the theory are: knowing, being with, doing for, enabling and maintaining belief. Knowing applies to the nurse knowing they have one’s life in their hands. Being with refers to the nurse being with the patient physically and emotionally. Doing for relates to what the nurse is doing for the patient such as controlling pain, assisting with activities of daily living, reclaiming the previous level of health). Enabling involves the nurse enabling the patient to self-care and self-healing. Maintaining belief consists of the nurse aiding the patient to maintain belief that they can get through this phase of recovery. Nurses need to get back to the basics of caring, work as a team for the patient. Nursing administration needs to make sure that nurses have enough support staff in order to allow more time for nurses to spend time with the patients. If the patients were not there, they would not be a need for any of them.

References

Moffa, C. (2015). Caring for novice nurses applying swanson’s theory of caring. International Journal for Human Caring, 19(1), 63–65. https://doi.org/10.20467/1091-5710-19.1.63

SAMPLE RESPONSE 5 FOR NURS 8114 Week 2 Discussion: EXPLORING MIDDLE RANGE THEORIES AND FRAMING PRACTICE ISSUES

You highlighted an interesting concern, healthcare quality can be affected by numerous factors, including outsourcing too many services. The current practice at your hospital seems to be one that strips away control from the facility in terms of maintaining high quality and standards as it is reliant on outside providers. Scheduling sounds like it would be an issue and patients would be asked to wait extensively for appointments or procedures that could be urgent. It is a responsible move on the healthcare system to attempt to be more scientific in adopting the strategy of outsourcing specialty services as it does come with monetary gains; it requires attempt to predict challenges and solutions before transferring services to external sources (Shaarbafchizadeh, Aghdak & Sahebi, 2020). Outsourcing care can become complicated as operational efficiency can increase when specialties outsourced are not needed however, it can create longer wait times when outsourced services are finally requested (Skipworth, Delbufalo & Mena, 2020). Better planning before transitioning to a model of outsourced services to ensure potential challenges have solutions in waiting to prevent patients from suffering. Outsourcing, if done correctly, can help staff to focus on their job function better to give patients the highest possible quality of care, while keeping care delivery costs down.

References

Shaarbafchizadeh, N., Aghdak, P., & Sahebi, M. (2020). Outsourcing in Health Facilities: Challenges in Medical University of Isfahan in Focus. International Journal of Preventive Medicine, 11, 172. doi: 10.4103/ijpvm.IJPVM_196_20

Skipworth, H., Delbufalo, E., & Mena, C. (2020). Logistics and procurement outsourcing in the healthcare sector: A comparative analysis. European Management Journal, 38(3), 518–532. doi: 10.1016/j.emj.2020.04.002

SAMPLE RESPONSE 6 FOR NURS 8114 Week 2 Discussion: EXPLORING MIDDLE RANGE THEORIES AND FRAMING PRACTICE ISSUES

A practice concern with my organization is access to quality specialty care. Resources in my community could be more extensive, especially with specialty care. We have one cardiology office, which makes quick consults impossible. Neurology, nephrology, gastroenterology, and urology are all an hour away. We have a standing ER, but the quality of care has diminished because of the lack of specialty care. If a patient needs hospital admission, they are transferred to another hospital an hour away. My community is like many other communities in the US that are designated as rural. Rural dwellers are less likely to have completed higher education, are older, and are usually veterans or uninsured (Cyr et al., 2019).

Middle-Range Nursing Theories

A middle-range nursing theory that incorporates the setting of my community is the Rural Nursing Theory. This framework notes that health is the ability to work and be productive ( Lee & Winters, 2004). Secondly, rural dwellers are self-reliant and resist accepting help from services or agencies (Lee & Winters, 2004). Lastly, the providers in the rural center lack anonymity (Lee & Winters, 2004), limiting their ability to have private lives. The rural nursing theory is valuable in addressing my community’s need for specialty services. Specifically, the rural nursing theory concept that most rural residents define health as the ability to work is a battle that I encounter daily. Health expectations differ; as long as patients can work and contribute to their household, they consider themselves healthy. Using this framework, I can propose healthiness with the ability to work. For example, I can approach controlling blood sugars in people with diabetes as imperative by expressing consequences that will prevent the patient from being able to work. Many of my patients are local truck drivers; the only way these patients make money is by driving a truck. However, this right to drive can be revoked if they do not have control of their blood pressure, blood sugars, or sleep apnea. Unfortunately, because of the idea of health as being able to work, patients do not present at the beginning of this diagnosis, and they do not come in for preventive care. Warranting specialty care consults. 

Furthermore, Florence Nightingale’s Environmental nursing theory can evaluate the rural environment and assess its effects on specialty care. The basic concept of environmental nursing theory is that the patient’s physical environment can affect the well-being and healing of the patient (Gonzalo, 2019). With this theory, I would assess my local community to identify the barriers to specialty care. Is transportation the primary barrier, or could traveling to specialty care take too much time out of the work day? Once the identity of the barrier is exposed, interventions can start. For example, if traveling takes up too much of the patient’s time, I could try to access specialty care through telemedicine. If lack of transportation is a barrier, I would contact local taxi companies and see if, with the local government, a grant could help pay for transportation. 

Many different nursing theories can be used in a rural setting to improve the overall health of residents. All require interdisciplinary collaboration and local government support. As a DNP-prepared nurse, I will have the knowledge to make a real change. 

References 

Cyr, M. E., Etchin, A. G., Guthrie, B. J., & Benneyan, J. C. (2019). Access to specialty healthcare in urban versus rural US populations: a systematic literature review. BMC health services research, 19(1), 1-17.

Gonzalo, A. (2019). Florence Nightingale: Environmental Theory. Nursing Theory Guide.
Lee, H. J., & Winters, C. A. (2004). Testing rural nursing theory: Perceptions and needs of service providers. Online Journal of Rural Nursing and Health Care, 4(1), 51-63.