Little Town Lifelines
Katelyn Alvarez strides resolutely around the emergency room at Barton Memorial Hospital, attending to patients that stream in from a crowded waiting room. She treats one patient for severe septic shock, then inputs critical lab values at the nurses’ station before whisking away to assess another patient for neurological function and consult with a doctor on IV antibiotics.
Located in the heart of the Tahoe Basin, the hospital is a blend of rustic charm and state-of-the-art medical care. Barton serves South Lake Tahoe’s 22,000 year-round residents, and its emergency room, with only 14 beds, can quickly stretch thin treating the usual smattering of auto accidents, elderly afflictions, and frequent flyers. Its nurses see a little of everything here, not to mention this year’s especially virulent flu strain.
Barton is also a 15-minute drive from Heavenly Ski Resort, so it treats its share of recreation-related injuries. When the Tahoe Basin population balloons to 250,000 visitors during the winter and summer, the area’s emergency rooms can be quickly overburdened.
Alvarez never ceases moving, though, revealing a quiet confidence that belies the chaos around her. This busy morning marks her final shift at Barton—in four days she resumes classes to finish up in Chico State’s nursing program.
Alvarez is one of 33 students who participated in the University’s Rural California Nursing Preceptorships (RCNP) program this winter. Since 1975, the RCNP—perhaps the only program of its kind in the country—has placed senior-level and graduate nursing students from all over the nation into Northern California rural and semi-rural hospital settings.
These students receive 150 hours of hands-on clinical experience over three weeks that they likely wouldn’t get if they were precepting in a larger hospital in a metropolitan area, where a student nurse may merely shadow the nurse preceptor. Instead, working in hospitals with as few as eight beds or perhaps only a few dozen, they fill a vital role in providing critical care.
“This program is definitely life-changing because it gives you the experience that you don’t get in the classroom,” said Alvarez, who is set to graduate in May 2018. “I’m a big believer that a lot of the learning happens beyond the classroom doors, and there’s a lot of learning by doing.”
And Alvarez did more than she ever imagined this winter: She learned how to make safe decisions under duress. She maintained airway and respiratory functions while transferring patients in a helicopter. And she practiced comforting her patients when they were most vulnerable.
The RCNP program, supported and administered through the Chico State Research Foundation, has placed more than 2,200 students since its inception over four decades ago. Half are Chico State, Butte College, or Shasta College students. The rest come from other areas in California and even out of state, traveling from places like Mississippi, North Carolina, and Massachusetts.
Program coordinator Kathleen Kirby says the main takeaway for students is increased confidence the hands-on clinical training helps cultivate.
“If someone is more confident, then learning becomes more fun, and they’re able to absorb information better,” said Kirby (Latin American Studies, ’91), who has led the RCNP program for 22 years. “You can’t fake confidence, and confidence comes from exposure.”
The 32 partner hospitals are as diverse as the 12 counties the program serves, extending north to the Oregon border and as far south as Bishop near Mammoth Lakes.
The RCNP is not a requirement for the University’s five-semester nursing program, costs students around $1,000, and does not provide any academic units. However, students begin applying as early as their third semester, and Kirby accepts only the top students, “around the 90th percentile,” she says, based on previous clinical performance rated by nursing faculty.
Students could be placed in tiny nine-bed Eastern Plumas Hospital in Portola, Hollister’s Hazel Hawkins Memorial Hospital (49 beds), or even Enloe Medical Center in Chico, the program’s largest partner hospital, with 298 beds.
Originally funded by a federal grant, the RCNP program was a response to a chronic nursing shortage in North State rural areas. The program sought to introduce nursing students from urban areas to smaller and more intimate hospital settings. The idea was students would gain valuable hands-on experience and bolster their résumés, while giving hospitals extra hands to help on the floor.
Ideally, Kirby noted, the students would fall in love with rural nursing and continue their careers
at rural hospitals. Although the program has not resolved the shortage of medical professionals in less urban areas, with only a small percentage pursuing a rural path, those who do stay make a big impact.
Taylor Jensen was placed into the emergency room at Sutter Amador Hospital in Jackson, one hour east of Sacramento, as an RCNP student nurse in summer 2012. Having grown up in Auburn, Jackson’s small-town feel reminded him of home.
Sutter Amador is the only hospital for Jackson’s residents (numbering fewer than 5,000), who seldom have a primary care physician due to poor access to health care. As a result, patients visit Sutter Amador often as a last resort.
“They’re often in septic shock, as they sometimes live up to an hour or more from the hospital,” Jensen said. “The ER nurses and doctors are often the only medical personnel these patients ever see.”
In addition to ER nursing skills, Jensen became adept at other specialties including geriatric, family medical, acute psychiatric, and discharge planning.
Upon graduating in December 2012, he returned to work in the ER at Sutter Amador, where he’s been ever since. Remembering his patients’ names puts them at ease, and his familiarity with them only grows as he runs into them within the community, outside the hospital.
“These relationships create trust, and it shows,” Jensen said. “We consistently have some of the highest benchmarks in the Sutter Health Network, not just for patient satisfaction and outcomes, but employee satisfaction as well.”
At the north end of the Sacramento Valley, Red Bluff is nestled between California’s Northern Coast and Sierra Nevada Mountain Ranges. St. Elizabeth Hospital serves this town and its community of about 15,000, and its 76 beds are a fraction of the number available at larger Chico and Redding hospitals, about 30 minutes away.
Nursing student Daisey Villegas completed her winter preceptorship in the 16-bed emergency room here under the guidance of Roxann Higgins (Nursing, ’14). Set to graduate in December 2018, Villegas describes how her RCNP experience impacted her future ambitions.
“Even before I started at St. Elizabeth, I knew I wanted to be an ER nurse,” Villegas said. “Now I have the passion.”
Villegas, a first-generation student from Santa Rosa, said her experience has helped her grow beyond measure.
“I was drawn to it because I like working in a small community. I’d love to work in a bigger hospital because you’ll get more action, but in a smaller hospital, you get that bond with the patients,” Villegas said. “Having that close community really does help you grow as a nurse.”
She peppered her preceptor with questions as they worked, and Higgins patiently answered every one, using each case as a learning opportunity, pointing out symptoms, and prioritizing care strategy.
“Whenever there was a patient the staff knew was a teachable experience, they would seek me out and explain the situation and let me improve on my skills,” Villegas said. “And the patients were all supportive of me as a nursing student. It was such a positive learning environment.”
If you’re healthy, it’s an easy drive from Red Bluff to Redding or Chico. But in an emergency, the time to drive 30 miles could be the difference between life and death.
While infrequent, St. Elizabeth is certainly no stranger to urgent care, said Higgins, a registered nurse who has been precepting RCNP students for several years. It can be as simple as a heart attack or vehicle crash, or as complex as mass trauma.
During last year’s deadly Rancho-Tehama Reserve shootings—which made national news when five people were killed and 18 others were injured—three patients were admitted in Red Bluff after the area’s lead hospital became overwhelmed by the number of critical patients.
“We provide an incredible service to this community,” Higgins explains. “People, I believe, would die if we weren’t here because they can’t get to Chico or Redding.”
RCNP students pair up with the same preceptor for their 12-hour shifts four days a week. A mentorship is quickly established, and the preceptors track student progress through daily feedback to create a comfortable learning environment. The students can then dedicate their time to providing patient care for the full three weeks.
Each year, Higgins is invigorated by her wide-eyed students’ energy, willingness to learn, and enthusiasm to make a difference in the world.
“They keep me from being too cynical. Nursing in general, and particularly emergency room nursing, can be sad and there are things that happen that we can’t fix,” Higgins said. “But having a student around, they’re full of enthusiasm and they want to do good for people.”
She’s found the experience, especially teaching fellow Wildcats, extremely gratifying.
“I do feel a real sense of pride when I tell people where I went to school,” she said. “Helping Chico State students cements that feeling of pride and gives me renewed enthusiasm for nursing and for encouraging students to never stop learning.”
The 150 hours Higgins spends with her students, like Villegas, are critical to preparing them to become the most experienced nursing graduate they can be. This means she facilitates learning by supervising and gradually handing over the reins.
“You can read about nursing, about the theories and foundations. You can practice skills in a skills lab,” said Higgins. “But actually putting your hands on patients and being able to perform procedures and interact with people is something students typically don’t get much experience with until they become a nurse.”
Before arriving at Barton in South Lake Tahoe, Alvarez’s clinical experience comprised of surgical, obstetrics and gynecology, and intensive care units as part of her nursing studies. But she was limited one or two clinical shifts a week, and paired with different nurses each time. The inconsistency, while not uncommon in nursing school, can interfere with opportunities for greater learning.
“I would need to reintroduce myself and my competencies with each new nurse, and I would spend a great amount of my clinical time searching through my patients’ charts for my logs,” she said.
In contrast, her RCNP experience made her feel truly prepared.
“The program increased my confidence to be a team player and to understand my role as a nurse from the beginning of the day to the end,” said Alvarez.
That confidence and aptitude is intentional, as RCNP works to fight nursing’s trend of attrition. Often, undertrained and unprepared nurses can become overwhelmed by the sheer vastness of their jobs when plunged into a daunting clinical setting.
“New nurses would find that they were suddenly helping patients with their normal activities of daily living—bathing, and eating, then one needs a box of tissues, and another needs help to the bathroom—while at the same time you’re injecting very serious medications and calling the doctors,” Kirby explains. “It’s a juggling act, and when you’re so new, you don’t have a sense of priority of what needs to be done first or how to delegate.”
Kirby said 30 percent of nursing graduates exit the field within their first year to seek other careers. She was one of them.
As a fresh-faced nurse, Kirby went straight from earning her AA in nursing to working in a hospital. Because she lacked vital clinical experience, she felt completely overwhelmed by the fast pace, multiple responsibilities, and need to learn on-the-fly in a stressful environment. So, she left.
“I should have been in this program,” Kirby said of RCNP. “I had two weeks of orientation as a brand-new
nurse, and I didn’t know what the hell I was doing. It was terrifying.”
Kirby notes that the steepest learning curve for new nurses happens in the first 18 months. The idea for RCNP students is that having nearly a month of additional clinical experience will flatten that curve. It also helps them get in the door.
A recent survey of the University’s nursing alumni reported 100 percent job placement within a year after graduating. Notably, Kirby reports, RCNP students were more likely to be hired first.
“You’re a changed human for having done the program,” Kirby said. “Any time you do something to conquer fear, it changes you.”