Understanding the Nursing Worlds Within Urban and Rural Hospitals

Some of the best obstetric nursing care in the country is found along the bedsides of Boston hospitals; an abundance of specialists, advanced tools, knowledge, and constant exposure to a variety of procedures and emergencies help keep nurses sharp, leading to top level care for mother and infants.

But what about obstetric nurses in rural hospitals? What are their challenges? And how does that affect the care given to an expectant mother and her infant? 

IHP Assistant Professor and obstetric nurse researcher Samantha Bernstein is finding out. Using a seed grant from the School of Nursing, Bernstein is examining how the work system affects obstetric nurses working in rural hospitals.

“Most of the research looks at how sick the patients are and, not that it’s not relevant, but that's the thing I can't change,” said Bernstein. “So, I'm more interested in understanding, ‘What's it like to be a nurse in these environments? And what can we do at a systems level that will improve the care that patients get by improving what nurses have access to and how we work?’”

Three rural hospitals are being utilized in the study, including Mass General Brigham members Martha's Vineyard Hospital and Nantucket Cottage Hospital. Monadnock Community Hospital in Peterborough, NH is the third facility. Most have between 10 and 15 nurses, one or two obstetricians, a midwife, and two anesthesiologists. Bernstein has conducted site visits to Martha’s Vineyard, Nantucket Cottage and Monadnock Community hospitals and is currently compiling the data for analysis.

“In a lot of rural spaces, I’m finding that our obstetric patients have gotten really much sicker over the last generation,” remarked Bernstein. “Nationally, our maternal morbidity and mortality is the worst in the developed world and some of that is our systems, and some of it is our patients are sicker than ever. They are more likely to have diabetes and heart disease and obesity. They're coming to us much sicker.

“The problem is, because a lot of the research gets done in urban specialty care centers, most researchers don't really know the systemic approach in the rural hospitals. And often rural hospital nurses grew up in that rural place, went to nursing school in that rural place, and now they're working in that rural place. They may not really have any sense of what's going on like beyond the boundaries that they're used to.”

Bernstein’s research will provide a window into two vastly different hospital worlds: from large medical centers in urban settings that may provide highly specialized, quaternary care to much smaller, community-based hospitals in rural settings where obstetric nurses need to wear multiple hats. And vice-versa. 

Bernstein is among the few researchers examining how nurses work, what tasks they do, and how the work environment affects them when their patients get sick and need care escalation. 

“When we sit down to chart, do we have enough computers? How many steps does it take us to get the medications if we don't have the medication on the floor?” asked Bernstein, rattling off just some of the questions her study will look at in each hospital she visits. “How do nurses get the medication? Do we have to call pharmacy? Can someone bring it to us? All those things that aren't the nurse and aren't the patient - the everything of it.”

Bernstein first studied systems level factors in 2021 at Massachusetts General Hospital, a highly resourced facility that still presented challenges for obstetric nurses. 

“Those nurses have certain kinds of systems factors that affect them, having to do a lot with the architecture of their floor,” said Bernstein. “Their floor was built to do about 2,400 deliveries a year, and now it's doing 3,600, so they're pretty crowded.”

Nurses cope with technological issues like lost and broken cables or having to call the pharmacy for medication. 

“But they know that if they need help, they can get it,” said Bernstein. “They don't have a shortage of people and they don't have a shortage of knowledge, or training.”

That’s not the case in rural hospitals, where Bernstein says most everything is in short supply. For example, a common scenario in obstetrics is mothers who hemorrhage after they give birth. 

“At a community hospital, they probably have ten units of blood in the entire hospital, and not all of them are going to match any individual patient,” points out Bernstein. “That’s an astonishing thing to have to deal with. If you work in a tertiary care center, you can pretty much push a button and they'll bring you six units of blood that match your patient in less than ten minutes.

“So, the difference in practice is really profound. On the one hand, the nurses at the big specialty care centers are amazing at taking care of really sick patients. They take care of people in labor who have had heart transplants – really, really sick patients – but they do so with this tremendous bench of people who can help them.”

On the flip side, rural hospital staffs treat mostly healthy pregnant mothers, and that can be a problem. 

“Anyone with any condition can walk in at any time,” said Bernstein. “You're used to taking care of mostly healthy people but it can go sideways. You can have someone hemorrhage after they give birth. You can have bad things happen, and when that happens you have to scramble to do something you only do a few times a year.”

As is the case with any research, the goal is to move the needle and hope the information uncovered makes healthcare better for patients down the road. 

“My hope is that research like mine will improve the communication between the large urban and small rural hospitals so that we know what each other's jobs are like, and we can work better together for our families,” said Bernstein. “When I'm working in a rural space and I have to call a helicopter, which is a bunch of steps, and then I'm calling that large hospital saying, ‘I need to send you my patient,’ sometimes I think they're a little frustrated with me that I can't do things. I think if they understood my work environment, they wouldn't be frustrated with me."

“I also think if we had better training on the rural side, we'd be able to handle a few more things - even given our limited resources. We’d also understand what it's like at the other end of the line, and why those people are so overwhelmed when we call them because they're dealing with these things that we never have to deal with.”

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