Overcoming Challenges of Education in Rural and Remote Settings


Published: 03 September 2018

Rural hospitals account for more than fifty percent of all hospitals in the United States.

Rural health centres provide a wide range of essential services including: acute care, ambulatory care, and emergency medical and psychiatric services (HRSA, 2018).

Nurse educators that are charged with the assessment, implementation and evaluation of continuing education in rural settings face daily challenges that are unique to these geographically isolated health care settings.

There are a number of strategies nurse educators can employ to minimise and surpass these challenges. One strategy is to utilise the nursing metaparadigm as a foundation for program planning, implementation and evaluation.

The Nursing Metaparadigm

Jacqueline Fawcett (1984) stated that the focus of the nursing discipline had evolved around select global concepts. Fawcett emphasised that nursing had reached a stage of foundational clarity, with a central metaparadigm at the top and multiple paradigms flowing from it that support the evolution of nursing theories and knowledge.

According to Fawcett, there are four central concepts that unify and feed into the central metaparadigm:

  1. Nursing;
  2. Person;
  3. Health; and
  4. Environment


The concept of human caring is central to the definition and foundation of nursing practice. The nurse is the agent of care, and that care is a source of power. The power of caring is based on scientific theories and nursing research.


The person is the focus of the need for care. For bedside nurses working in rural and remote settings that may be an individual patient, their family members, friends, or the community as a whole.

Additionally, it is important to remember that often, the ‘persons’ are professional nursing colleagues, restricted due to geographic boundaries to seek continuing education within their local practice area.


Health is an active and evolving process and is directly influenced by the viewpoint of the individual across their life span.

The essence of wellness is the experience of balance between a person’s possibilities and their realities and it’s based upon caring and feeling cared for.

A person’s view of health is constantly influenced by their interactions with the environment.


Environment forms the back drop of human social experience.

In encompasses differences in location, time and quality, and also personal, socio-cultural, national and historical factors.

Environment also includes customs, values and beliefs of the persons who are the recipients of care.

Dimensions that may affect health include physical, psychosocial, cultural, historical and developmental processes, as well as the political and economic aspects of the social world.

Utilising the Metaparadigm to Minimise Barriers

When I am planning an educational program, I begin by reflecting upon the four concepts of the metaparadigm.

Often times, my attention is immediately drawn to the concept of environment. Environment is typically the biggest challenge that I face as an educator in rural settings and this is just one example of how I overcame this barrier.

In early May 2018, I received a request from several nurses asking for education about how best to communicate and provide care for the growing number of LGBTQ patients that were seeking care in a rural hospital.

The nurses told me that they did not know how to properly and effectively communicate with this population of individuals and so they wanted education and information specifically on health promotion needs.

I immediately came up against several barriers to planning and providing education to the nurses on this topic:

  1. Location;
  2. Geography;
  3. Reach; and
  4. Person.

This rural hospital only had a small conference room with a capacity for twenty people; not big enough for what I required. I began to investigate local restaurants, conference centers, however there were none in the area.

I instead came across a farm within 8 miles of the hospital, where the owner opens the converted barn to nonprofit organisations holding open meetings and presentations.


The next environmental barrier was the weather: the area experiences significant snow from early November. Fortunately, I was able to book the venue for early October!

Our geographic barrier was addressed.

An enduring barrier for educators working in remote settings is around the inability of many nurses to attend sessions. This could be for a variety of reasons.

I organised for the presentation to be recorded using video technology so that nurses who are unable to attend the live presentation will be able to view the recording at a later date.

The next challenge would be to find an educator that could address this highly specialised subject. Person is the most central concept of the metaparadigm.

The center for nursing research in the western portion of our state is located about 60-miles from our program location. I contacted a colleague there who had spoken to our members on a variety of specialised topics and asked her advice.

She immediately referred me to a nurse practitioner who provides care for LGBTQ patients.

The nurse practitioner enthusiastically agreed to deliver a presentation utilising case studies and role play activities to engage the participants. The use of case-studies throughout the presentation will allow the speaker to influence cultural humility and person-centered care to throughout the program presentation.

This presenter possessed the power to provide the education and care for this audience of fellow nurses because of her clinical background specialising in the primary health needs of LGBTQ persons, her academic preparedness and her openness regarding her place as a fellow member of the LGBTQ population.


The obstacles that exist for nurse educators working in rural and remote settings are ever-present, and at times seemingly insurmountable. The metaparadigm offers educators a strategy to minimise those challenges and support the needs of the person seeking care and knowledge.

Therefore, please consider that if you encounter “locked doors” in your process of planning, implementing, and evaluating educational programs in rural and remote settings, the metaparadigm may provide an open window towards a positive resolution.


  • Bender, M. (2018). Re-conceptualizing the nursing metaparadigm: Articulating the philosophical ontology of the nursing discipline that orients inquiry and practice. Nursing Inquiry, 25(3). 1. doi: 10.1111/nin.12243
  • Fawcett, J. (1984). The metaparadigm of nursing: Present status and future refinements: Image: The Journal of Nursing Scholarship, 16(3), 84-87. https://doi.org/10.1111/j.1547-5069.1984.tb01393.x
  • Hawkins, J.E., Wiles, L.L., Karlowicz, K. & Tufts, K.A. (2018). Educational Model to increase the number and diversity of RN to BSN graduates from a resource limited rural community. Nurse Educator, 43(4). 206-209.
  • Johnson, E.M., Jones, K., Eathington, P., Howard, C., Raszewski, R. & Twigg, N.M. (2017). Next: Creating an interdisciplinary alliance to diminish informational barriers for public health nursing. Health Information and Libraries Journal, 34. 236-246. doi: 10.1111/hir.12184
  • Rural Hospital Programs (2018). Health Resources & Services Administration (2018). Retrieved from: https://www.hrsa.gov/rural-health/rural-hospitals/index.html
  • Nurse Watch: Nurses Again Top Gallup Poll of Trusted Professions and Other Nurse News (January 10, 2018).  American Hospital Association. Retrieved from: https://www.aha.org/news/insights-and-analysis/2018-01-10-nurse-watch-nurses-again-top-gallup-poll-trusted-professions


educator profile image
Judith Paré View profile
Judith Paré joined the Massachusetts Nurses Association (MNA) in May, 2017 as the Director of Nursing Education/Workforce Quality and Safety. In 2014, Judith earned her Doctorate of Philosophy in the field of Nursing Education Capella University. Prior to joining the MNA she was Dean of the School of Nursing & Behavioral Sciences at Becker College in Worcester Massachusetts. She is an experienced educator in academic and continuing education settings. Judith is a member of more than ten professional nursing organisations and she devotes much of her time as an advocate for the Rural Nurse Organisation. Her expertise include curriculum design, assessment and evaluation in nursing and healthcare. Her research areas of expertise in rural healthcare and specifically the lived experiences of the rural nurse generalist. Judith is a published author and a national speaker in the field of rural nursing. Her recent writings includes: Montgomery, S, Sutton A & Paré, J 2017, ‘Rural Nursing & Synergy’, Online Journal of Rural Nursing & Health Care, vol. 17, no. 1, pp. 87-99. http://dx.doi.org/10.14574/ojrnhc.v17i1.431