Perceptions of Nursing in Appalachia: A State of The Science Paper

Perceptions of nursing in Appalachia is an emerging topic in nursing practice. The changing health care needs, advancing medical science, and the common sociopolitical factors have influenced the evolution of the nursing profession. The career primarily focused on alleviating suffering, healing, and promoting health (Brewer, 2018).

 However, the nursing profession has been broadened to encompass the cultural diversity representing the communities that they serve in recent years.

This paper explicates the perception of nursing in Appalachia, a region with distinct cultural characteristics that influence health care delivery, practices, beliefs, and availability.

Healthcare and Perceptions of Nursing in Appalachia

One of the primary reasons for health inequalities in the world is the lack of access to healthcare. This is particularly the reality in rural, medically underserved, and weak areas such as in Appalachia in the United States (Wilson, Kratzke, & Hoxmeier, 2012).

The Appalachia is a geographical area made of 205,000 square miles in 13 states and 410 counties and spans from northeastern Mississippi to the Southern Part of New York (Ford, 2018).

Isolated valleys and rugged topography make it a less-traveled area with low population density.

In this area, the factors that function as a barrier to healthcare include language barrier, lack of health insurance, and lack of financial resources, rurality, and lack of transportation. The Appalachians have had some of the lowest health indicators and highest poverty levels in the United States.

Categorized as an economically disadvantaged region, the Appalachians are home to a unique patient population that seeks special consideration (Roberson et al., 2018).

The terrain in the Appalachian has made it physically impossible for modern advancements and technology to spread into the area. Such factors create a unique culture for Appalachian residents.

West (2019) indicates that physical isolation has created resilient and distrustful people who seek independent and close-knit family units as well as a strong local community.

Perception of Nursing in the Appalachian

The nursing perceptions in the Appalachian are categorized into three, including how the Appalachian patients perceive nursing, how Appalachian communities perceive nursing, and how education leaders and nurses perceive nursing.

Nursing Perceptions by Education Leaders and Nurses

The three subcategories under this category include nursing leadership, advanced practice and advanced education, and inequality in educational preparation.

Education Preparation Inequalities

The Appalachian area is largely characterized by disparities in education, mostly caused by the high levels of poverty in the region. While approximately 70 percent of learners in the United States attend college, the proportion in the Appalachian is only 50 percent (Brewer, 2018).

Furthermore, the learners in the Appalachian do not get the support to seek further education. There is a need for culturally competent nurses and education programs to support these learners.

Advance Practice and Advance Education

There is a difference between the cultural characteristics of the Appalachian and nursing perceptions. Most of the people in this area do not leverage the possibilities of modern technology to advance their education or even use aspects such as telemedicine to provide care since they prefer face-to-face interactions.

Leadership in Nursing

Appalachia is a largely patriarchal society with men functioning as the providers for their families and performing roles such as farming and hunting meant for men. For men who become nurses, they have demonstrated leadership skills. Most nurses have stepped up to lead and manage health care change in the region.

Appalachian Communities’ Nursing Perception

Under this category, the perceptions are divided into nurses as members of the Appalachian culture and nurses as advocates.

Nurses as Advocates

Nurses in the Appalachian have continued to function as community advocates and pushed for better health care in the area. For instance, there has been a push for mobile health clinics to provide healthcare to this underserved population (Brewer, 2018). They have also championed various health promotion interventions, such as the diabetes self-management intervention among the community members.

Nurses as Part of the Culture

Nurses are also members of the Appalachian community. They have experienced some of the things that define the Appalachian people, such as inconsistent or limited law protection or enforcement, geographical isolation, patriarchy, and poverty. For instance, Brewer (2018) indicates that approximately 9.9 percent of the healthcare workers have been treated violently as children, and 17.5 percent have been sexually abused as a child.

Nursing Perceptions by Appalachian Patients

In the Appalachian, nursing is regarded as a noble and trusted profession. The primary role of nurses is to keep family members at home and offer social support to patients (Brewer, 2018). The social isolation of the region makes them resistant to the outside, and they mostly seek help from church members of the family.

For the Appalachian nurses, they also have a gatekeeping role and a valuable source of support. Nurses also provide care services characterized by self-worth and dignity, which is vital in the Appalachian culture.

Nurses also provide patient education, but family members remain the primary source of information. Based on the Appalachian cultural values, the treatment unit is the family.

Therefore, nurses serving Appalachian patients should recognize the significance of the family structure and engage in community activities (West, 2019).

It is also crucial for the nurses to provide culturally competent care to the patients like, during end-of-life care; they can incorporate folk and biomedical therapy.

Culturally appropriate care strategies may also include having conversations even on general topics such as the weather. The idea is for the patient to establish personal relationships with the providers to circumvent the strained outsider-patient relationship.

Appalachian cultural features support sensitive, non-confrontational, nonjudgmental, and accepting communication techniques (Brewer, 2018). Through responsiveness, kindheartedness, thoughtfulness, listening, kind treatment, and reverence, nurses, also provide the patients with spiritual support. Church members in the Appalachia view nurses as sources of support, counselors, friends, and approachable.

Nursing in the Appalachia

The general suspicion for outsiders such as health care providers and the isolated attitudes of the Appalachian residents presents a challenge to access to health care and facilitates poor health outcomes (West, 2019).

Therefore, it is the nurses’ responsibility to establish how the rural Appalachian culture influences the patient’s behavior

 Omitted medications, missed appointments, and noncompliance are mostly influenced mainly by the rural isolation and the transportation burden to pharmacies and appointments.

Trusting herbal medicine and home remedies could be attributed to distrust of healthcare profession outsiders and a lack of proper education about modern medicine.

Overall, despite the organizational and educational disparities that exist in the Appalachian, nurses have established strategies to provide skilled and competent care.

For instance, nurses evaluate the issues with transportation, monitor the limitations and benefits of the Appalachia home support system, and understand the education levels of the patients.

They also offer patient education, especially on the significance of attending the medical appointments to help in coordinating their care to reduce the number of hospital trips made.

They should also reiterate the importance of adhering to the medication regimen and maintaining proper communication with the providers.

Nurses serving the Appalachian population, both outsiders and locals ought to understand that this population does not have the same access to information and resources like the other areas in the United States; hence, their care interventions should be adjusted accordingly.


Brewer, E. P. (2018). Perceptions of nursing in Appalachia: A state of the science paper. Journal of Transcultural Nursing, 29(1), 6-13.

Ford, J. (2018). Equality of Opportunity in Appalachia (Doctoral dissertation, Georgetown University).

Roberson, P. N., Miller, M., Lloyd, J., Bell, C., Heidel, R. E., & Bell, J. (2019). Economic disparities in Appalachia linked to risk factors for long-term health for estrogen-positive breast cancer patients. Cancer Treatment and Research Communications, 19, 100128.

West, E. (2019). Rights and Claims: Culture and Communication in Appalachia. In Frontier Nursing in Appalachia: History, Organization, and the Changing Culture of Care (pp. 15-38). Springer, Cham.

Wilson, S. L., Kratzke, C., & Hoxmeier, J. (2012). Predictors of access to healthcare: what matters to the rural Appalachians? Global Journal of Health Science, 4(6), 23-25.

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