Barbara Hope, RN, thought there might be greener pastures in the bluegrass of Kentucky. But as far as nursing goes, what she found in taking a big step from Louisville hospitals to the smallest of community facilities is that it is different, not necessarily better.

With less than a year at Casey County Hospital in Liberty, Ky., population 2,500, Hope is reserving judgment.

“I felt like I needed some peace and quiet. So I moved to a small town,” Greensburg, population 2,000. From there, she commutes an hour through deer-rich country to work the 7 a.m. to 7 p.m. shift at Casey County, about 65 miles from Lexington. “It’s easier in a small town,” she said, “to come right into a day shift,” which was attractive after six years of night shifts in the city.

“I work in a 15-bed hospital. Two doctors, one floor, one emergency room and that’s it. We have X-ray. We have a lab,” she said. Contrast that with her first seven years of nursing at two metro Louisville hospitals—three years in transplants and the last four in intensive care and cardiac care units.

On the positive side, Hope, 34, said she can always reach one of her hospital’s two physicians. “You just call them at home or on their cell phones,” she said. “And they know who you are. You don’t get a resident who’s on call for them who doesn’t know what’s going on with their patients. So that’s a good thing.”

Familiarity with patients extends to nursing staff and the patients themselves, too. “We’re in the middle of Kentucky,” Hope said, and then added, half-kidding, “They’re all related. Everybody in this town knows everybody. All the patients know each other.”

It’s not uncommon to have five patients, at least two of whom have the same last names, she said. “It just makes it interesting. It’s not a good or bad thing, just interesting.”

At such a limited facility—which is classified as a critical access hospital, meaning that the federal government allows it some leeway in operating to preserve care in a medically underserved area—cases run the gamut from children with broken bones to elderly patients with do-not-resuscitate orders and med/surg patients admitted for transfer to larger facilities, Hope said.

But if one thing stands out, it’s respiratory problems. First, “about half of Kentucky smokes,” she said. There are cases of pneumonia and chronic obstructive pulmonary disorder in a largely elderly population, and allergies for everyone. “There are funguses that aren’t anywhere else in the world in people’s lungs in Kentucky,” and histoplasmosis is not unknown up and down the Ohio Valley, Hope said.

Her change of scenery also came with staffing issues, wider responsibilities and accepting less pay, at least psychologically.

“I do a lot of patient care and I don’t always have enough people to have an aide,” Hope said. With five or more patients, she said, she may work with an LPN, a certified nurses aide and sometimes a ward clerk. On the other hand, “If there’s only three [patients], I might be the only one there,” she said.

Of course, as in any hospital, “You can have five people who are no trouble at all or three people you can’t keep up with,” Hope said. “Even if it’s a teeny, tiny place, you still have stress. People don’t understand that you’re only one person and you have only two hands and can be in only one place at a time.

“When the pharmacist leaves at 2 o’clock in the afternoon, I’m the pharmacist. I’m the only one with keys to the drugs,” she said. “I do everything: Answer a lot of phones. Talk to a lot of families.”

Surprisingly, Hope said, “When I worked at bigger hospitals, their nursing really focused on how to retain employees.” That’s not been her experience in rural Kentucky. “I had no orientation whatsoever,” Hope said, not to mention a lower pay scale and poorer benefits.

She said she took a pay cut of about $10,000 a year—more than $5 an hour—to buy into the rural lifestyle. “But the cost of living is less, too. Things are cheaper, so it evens out,” Hope said.

For nurses who might be considering “dropping out” into a rural setting, Hope said her best advice is to stop and think about it. It’s difficult to predict whether such a move would be right or wrong for a career. The one certainty is that it will be different, she said.