农村护理卫生服务研究：改善农村卫生成果的战略 | J Adv Nurs

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It is estimated that about 44% of the global population resided in rural areas in 2020 (World Bank, 2022). Rural health disparities are a global concern (Australian Institute of Health and Welfare, 2020; Scheil-Adlung, 2015; The National Academies of Sciences Engineering Medicine, 2018). In the United State of America (U.S.), rural residents often suffer poorer health outcomes than their urban counterparts (The National Academies of Sciences Engineering Medicine, 2018), and this is also the situation in many other parts of the world. Rural residents in Australia, for example, experience health disparities in a range of areas, including higher prevalence of health risk factors (i.e. tobacco smoking), chronic conditions, burden of disease, death and injury compared with residents of urban communities (Australian Institute of Health and Welfare, 2020). Globally, rural populations experience decreased access to healthcare as a result of diminished financial resources and healthcare worker shortages (Scheil-Adlung, 2015). In the United States (U.S.), rural hospital closures have resulted in decreased healthcare access and remain a persistent threat to 20% of the U.S. population who reside in a rural area (The National Academies of Sciences Engineering Medicine, 2018). Decreased rural healthcare access can lead to poor health outcomes that pose a threat to the future of rural populations globally. For example, there is an association between the decreased number of healthcare workers and increased maternal morbidity and mortality (MMR) in rural compared with urban areas across a national MMR quintile calculated by the International Labour Organization (Scheil-Adlung, 2015). The MMR ratio is 2.5 times higher in rural as compared with urban areas across the globe (Scheil-Adlung, 2015).

Access to the full range of healthcare services is important to promoting better healthcare outcomes in rural areas. One potential strategy to address challenges to access to healthcare for rural populations, and the subsequent poorer health outcomes is through attracting and retaining a well-educated and well-supported global rural nursing workforce. Rural nurses are in a unique position to serve as expert generalists for rural populations across the lifespan (Schlairet, 2017). However, it is not clear how well rural nurses are supported in their roles, and how factors related to their well-being (i.e. job burnout) could be impacting the rural nursing workforce and, subsequently, on rural population health outcomes. One way to determine how rural nurses influence rural health outcomes over time is through rural nursing health services research (Smith et al., 2021). The term rural nursing health services research (Smith et al., 2021) is an extension of nursing health services research, which is defined as “the study of health care delivery and systems of care delivery, examination of structures, processes and outcomes of nursing care, evaluating nursing practice innovations and new models of care delivery” (Buerhaus et al., 2019, p. 2; Jones & Mark, 2005). Nursing health services research differs from other research specialties, such as basic and pre-clinical research, because it has a broader system- and or population-level focus on assessing and improving the effectiveness of nursing structures, processes of healthcare delivery and associated health outcomes (Buerhaus et al., 2019).

The dearth of current information about how rural nursing structures and processes may influence rural healthcare access and outcomes contrasts against a growing knowledge base documenting positive associations between nursing structures and patient outcomes across large geographic urban areas (Sloane et al., 2018). Limited information about how rural nursing and healthcare access could influence rural patient outcomes is not due to a lack of nursing interest in the topic (Schlairet, 2017; Smith et al., 2021), but is related to system-level factors. For example, many rural hospitals and healthcare settings may be focused on remaining financially solvent due to continual threat of closure (The National Academies of Sciences Engineering Medicine, 2018), and so may be too overwhelmed to investigate the influence of nursing structures and processes on rural health outcomes.

Failure to conduct rural nursing health services research is a major missed opportunity for improving rural health outcomes, as understanding relationships among rural nursing structures, processes and outcomes could be the bases for managerial or policy-based interventions to address rural nursing resource deficits that, if addressed, could improve rural health outcomes locally, globally and internationally. Unique and persistent challenges such as lack of existing infrastructure dedicated to research in rural healthcare research impedes the conduct of rural nursing health services research that could help us to better understand how rural nursing could improve the health outcomes of rural populations.

Rural researchers generally have access to fewer existing resources than urban counterparts, and are therefore focused on pursuing funding from grant proposal calls that could support needed research. Available resources are extremely competitive, and submitting proposals for funding rural nursing health services research requires expertise in successful grant writing and if successful, infrastructure is needed to conduct research projects from beginning to dissemination. Nurses and others conducting research in rural communities and settings can face additional challenges associated with distance. Even access to reliable internet can be an issue in some rural and remote settings, and internet access is crucial to the conduct of large-scale rural nursing health services research.

Moreover, rural nursing health services research calls for greater engagement with communities and the use of innovative research methods across the healthcare continuum. This need for authentic community engagement can result in a longer start-up time as time is needed for developing and maintaining the necessary community relationships. It takes significant and sustained effort to gain the trust of rural populations needed to conduct in-depth research to understanding their health challenges and needs. These essential logistic challenges should not stifle the ethical imperative to address the lack of sufficient and cutting-edge knowledge that could serve as a basis for rural nursing structure and process interventions needed to improve rural health outcomes.

Even if the challenges of conducting rural nursing health service research are overcome, challenges in disseminating rural research results may serve as a barrier to sharing results with a larger global audience due to differing perceptions about the importance of rural research. There are also inherently smaller populations in rural areas, and thus, sample sizes obtained from rural data collection efforts may well be smaller than in urban settings. There is a risk for high-impact and prestigious journals desiring to publish studies with larger sample sizes to overlook the significance of rural nursing research that reports about smaller samples. It is important for editors and reviewers to consider the relative size of the rural sample to the overall rural population and the challenges of securing large samples in rural settings before dismissing findings from rural nursing health services researchers that could benefit rural population health. It is also crucial for authors to argue for the reasoning of smaller sample sizes in their papers through provision of appropriate contextual information, and selection of appropriate measurement tools that will deliver meaningful results from smaller samples.

Despite formidable challenges in focusing on, conducting, and disseminating rural nursing health services research, there is a pressing need to make significant advancements in the subfield of rural nursing health services research to generate the knowledge to inform how nursing structures and processes could improve rural health outcomes. Conducting rural nursing health services research could also provide important information about how best to prepare and support nurses to work in rural areas. One application of rural nursing health services research is using empirical findings to inform the design of interventions to strengthen leadership and advocacy skills for rural nurses. Rural nursing health services research should be expanded and supported on a global scale given the widespread inequities in rural compared with urban healthcare access, as a means to improve rural health outcomes through improved rural nursing structures and processes. It is time to stop overlooking the importance of rural nursing health services research as a potential avenue to improve rural healthcare access in the interest of improving the health of rural residents globally.

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据估计，2020年全球约有44%的人口居住在农村地区（世界银行，2022）。农村健康差异是一个全球关注的问题（澳大利亚卫生和福利研究所，2020；Scheil-Adlung，2015；美国国家科学工程医学研究院，2018）。在美利坚合众国（U.S.），农村居民的健康状况往往比城市居民差（美国国家科学院工程医学部，2018），这也是世界上许多其他地区的情况。例如，澳大利亚的农村居民在一系列领域经历着健康差异，包括与城市社区居民相比，健康风险因素（即吸烟）、慢性病、疾病负担、死亡和伤害的流行率更高（澳大利亚卫生和福利研究所，2020）。在全球范围内，由于财政资源的减少和医疗工作者的短缺，农村人口获得医疗保健的机会减少（Scheil-Adlung，2015）。在美国，农村医院的关闭导致了医疗服务的减少，对于居住在农村地区的20%的美国人口来说，仍然是一个持续的威胁（美国国家科学院工程医学部，2018）。农村医疗服务的减少会导致不良的健康结果，对全球农村人口的未来构成威胁。例如，与城市地区相比，在国际劳工组织计算的全国产妇发病率和死亡率五分位数中，农村的医疗保健人员数量减少与产妇发病率和死亡率增加之间存在关联（Scheil-Adlung，2015）。与全球的城市地区相比，农村地区的MMR比率高出2.5倍（Scheil-Adlung，2015）。

获得全方位的医疗服务对于促进农村地区更好的医疗效果非常重要。解决农村人口获得医疗服务的挑战以及随之而来的较差的健康结果的一个潜在战略是通过吸引和保留一支受过良好教育和得到良好支持的全球农村护理人员队伍。农村护士处于独特的地位，可以作为农村人口一生的专家通才（Schlairet, 2017）。然而，目前还不清楚农村护士在他们的角色中得到了多大的支持，以及与他们的福祉有关的因素（即工作倦怠）如何影响农村护理队伍，以及随后对农村人口健康结果的影响。确定农村护士如何长期影响农村健康结果的方法之一是通过农村护理健康服务研究（Smith等人，2021）。农村护理健康服务研究（Smith等人，2021）是护理健康服务研究的延伸，其定义为 "研究保健服务和护理服务系统，检查护理的结构、过程和结果，评估护理实践创新和新的护理服务模式"（Buerhaus等人，2019，第2页；Jones & Mark，2005）。护理健康服务研究不同于其他研究专业，如基础研究和临床前研究，因为它有一个更广泛的系统和或人口层面的重点，即评估和改善护理结构的有效性、医疗服务的过程和相关的健康结果（Buerhaus等，2019）。

目前，关于农村护理结构和流程如何影响农村医疗服务的获取和结果的信息匮乏，与越来越多的知识库形成鲜明对比，这些知识库记录了大型城市地区护理结构和患者结果之间的积极联系（Sloane等人，2018）。关于农村护理和医疗服务获取如何影响农村患者结果的信息有限，并不是因为护理人员对这个话题缺乏兴趣（Schlairet，2017；Smith等人，2021），而是与系统级因素有关。例如，许多农村医院和医疗机构可能由于不断受到关闭的威胁而专注于保持财务上的偿付能力（美国国家科学院工程医学部，2018年），因此可能不堪重负，无法调查护理结构和过程对农村健康结果的影响。

能进行农村护理健康服务研究是错过了改善农村健康结果的一个重要机会，因为了解农村护理结构、过程和结果之间的关系可以作为管理或政策干预的基础，以解决农村护理资源不足的问题，如果得到解决，可以改善当地、全球和国际的农村健康结果。独特而持久的挑战，如缺乏专门用于农村医疗研究的现有基础设施，阻碍了农村护理卫生服务研究的开展，而这些研究可以帮助我们更好地了解农村护理如何改善农村人口的健康状况。

与城市同行相比，农村研究人员获得的现有资源通常较少，因此，他们专注于从可以支持所需研究的拨款提案呼吁中寻求资金。现有的资源竞争非常激烈，提交资助农村护理健康服务研究的提案需要有成功撰写拨款的专业知识，如果成功的话，需要有基础设施来进行研究项目从开始到传播。在农村社区和环境中进行研究的护士和其他人会面临与距离有关的额外挑战。在一些农村和偏远地区，即使是接入可靠的互联网也是一个问题，而互联网接入对于开展大规模的农村护理健康服务研究至关重要。

此外，农村护理健康服务研究需要更多的社区参与，并在整个医疗保健过程中使用创新的研究方法。这种对真实社区参与的需求可能会导致较长的启动时间，因为需要时间来发展和维持必要的社区关系。要获得农村人口的信任，进行深入研究以了解他们的健康挑战和需求，需要大量持续的努力。这些基本的后勤挑战不应扼杀解决缺乏足够的前沿知识的道德要求，这些知识可以作为改善农村健康状况所需的农村护理结构和过程干预的基础。

即使克服了开展农村护理健康服务研究的挑战，由于对农村研究的重要性有不同的看法，传播农村研究成果的挑战可能成为与全球更多受众分享成果的障碍。农村地区的人口本身就比较少，因此，从农村数据收集工作中获得的样本量很可能比城市环境中的小。高影响力和有声望的期刊希望发表较大样本量的研究，有可能忽视报告较小样本的农村护理研究的重要性。重要的是，编辑和审稿人要考虑到农村样本与整个农村人口的相对规模，以及在农村环境中获得大样本的挑战，然后再否定农村护理卫生服务研究人员的研究结果，这可能有利于农村人口健康。作者在论文中通过提供适当的背景信息和选择适当的测量工具来论证较小的样本量的理由也是至关重要的，这些工具将从较小的样本中获得有意义的结果。

尽管在关注、开展和传播农村护理健康服务研究方面存在巨大的挑战，但迫切需要在农村护理健康服务研究这一子领域取得重大进展，以产生知识，告知护理结构和过程如何能改善农村健康状况。开展农村护理健康服务研究还可以提供重要信息，说明如何最好地准备和支持护士在农村地区工作。农村护理健康服务研究的一个应用是利用经验性的发现为设计干预措施提供信息，以加强农村护士的领导和宣传技能。鉴于农村与城市医疗服务相比普遍存在不平等现象，应在全球范围内扩大和支持农村护理健康服务研究，作为通过改善农村护理结构和流程来改善农村健康状况的一种手段。现在是时候停止忽视农村护理健康服务研究的重要性了，因为它是改善农村医疗服务的潜在途径，有利于改善全球农村居民的健康。