After her grandmother became sick, Shelly Deyo decided she wanted to be a nurse working with the elderly. Deyo also wanted to teach and work in management. She has found the perfect job in her current position as director of assisted living at St. Clare Meadows Care Center, a nursing facility licensed for 25 beds in Baraboo, Wis. In addition, Deyo works as a coach and preceptor with the Wisconsin Nurse Residency Program (WNRP), helping new nurses develop the critical thinking skills and knowledge base they need to successfully handle the unique demands of rural nursing.
Shelly Deyo, director of an assisted living facility in Baraboo, Wis., credits the Wisconsin Nurse Residency Program for giving her the skills and knowledge necessary for the unique demands of rural nursing.
Deyo credits WNRP for providing the support she needed to succeed when she was a new nurse graduate. “Being in the nurse residency program gave me a better foundation, more confidence and more knowledge in core nursing areas,” Deyo said.
Wisconsin’s program grew out of the need to improve nurse retention rates; many nurses change jobs or leave the profession within two years of graduating, according to Cella Janisch-Hartline, a nurse consultant with Rural Wisconsin Health Cooperatives (RWHC), which worked in conjunction with Marquette University to develop the federally funded WNRP. Janisch-Hartline pointed out that Deyo’s first job, in a hospital where she often worked alone and was responsible for as many as six patients at a time, wasn’t unique. Janisch-Hartline noted that studies show rural nurses often work alone on a shift and care for a wide variety of patient needs.
“Typically, these nurses were just out of school and had just passed their boards,” Janisch-Hartline said. “This setting places many demands and a lot of stress on new graduates to develop competency in a relatively short period of time. Since we implemented WNRP, retention rates have soared.”
In Oregon, the N2K Nursing Education Program, housed in the Oregon Health Career Center, is a response to critical nursing shortages, particularly in rural areas. The N2K program brings together health care providers and Oregon colleges in a partnership that recruits and trains employees from participating hospitals’ existing work forces. Since it began in 2001, approximately 120 nurses have graduated and returned to their home communities to practice.
At Mountain View Hospital, a 25-bed critical access hospital in Madras, Ore., Will Bean, nursing education and emergency department manager, welcomed four new nurses to the staff in March, all of whom had come through the N2K program. Three formerly worked as Certified Nursing Assistants at the hospital and one was a phlebotomist there.
“I’m confident we’ll still have at least three of the four here 10 years from now because they have deep ties to this community,” Bean said. “We’ve gotten four great nurses that we had a hand in selecting because of their strengths, and we trained them within our own system. If they’d left to go to another nursing school, we’d have had to fill their current position and there’s no guarantee they’d return here. This program is definitely a better alternative for us.”
Nursing shortages and retention problems in rural areas will likely be even greater issues nationwide as the baby boom generation retires and more RNs continue to work outside the rural areas where they live, according to an April 2009 Policy Brief released by the WWAMI Rural Health Research Center (WWAMI). The proposed solutions WWAMI lists in the Policy Brief mirror much of what Wisconsin and Oregon are already doing: support and expand nursing and distance education, encourage students from rural locations to pursue nursing because they are more likely to return to rural areas, and better prepare rural RNs through the use of rural-relevant curricula and opportunities.
Nurses Carolyn Dawson (left) and Jessica Draper, who graduated from Oregon's N2K nursing program in mid-March, prep for surgery at Harney District Hospital in Burns, Ore.
N2K: a different type of education
The Oregon Office of Rural Health has been a partner in bringing N2K to the state’s small, rural hospitals. Calling it “our most ambitious project to date,” Oregon Health Career Center CEO Gary Wappes said the Oregon Consortium for Nursing Education partnered with Mount Hood Community College at Gresham to develop a rural cohort separate from already existing nursing programs that were offered through Oregon colleges. Nursing students selected for N2K complete didactic education requirements from home via an on-line educational system and do their clinical training in their home communities and hospitals.
The advantage, Wappes said, is that students continue their jobs in the facility where they are employed, do coursework without having to leave their community, and then do most of their clinical instruction within the facility where they already work. Upon entering N2K, they agree to return to work for their employer for a specified period of time.
Bean said N2K’s OCNE (Oregon Consortium for Nursing Education) component is particularly advantageous for rural nursing because, unlike traditional nursing programs, OCNE starts nurses at a base level working in several different departments.
“That’s similar to what is happening in real working experiences in rural facilities,” he explained. “And as they gain experience, their level of educational challenges gets more intense. But they continue to work in all areas such as pediatrics, orthopedics, acute care, etc. So they get very well-rounded.”
The Office of Rural Health also pursued development funding through Medicare and Medicaid that allows rural hospitals to be reimbursed for a major portion of their costs for N2K. Robert Duehmig, Office of Rural Health communications director, said the funding mechanism reduces strain on rural hospitals’ budgets.
WNRP: sustaining new nurse graduates
Marquette University and RWHC developed WNRP six years ago, with funding from the Health Resources and Services Administration (HRSA), to continue education for new nurse graduates and to retain them long-term. Curriculum includes monthly educational sessions and mentoring by preceptors and clinical coaches that spans at least 15 months of a new nurse graduate’s employment. To date, nearly 400 rural nurses have completed the WNRP or are currently enrolled in the year-long program, and WNRP has trained more than 700 preceptors.
The nurse retention rate in RWHC rural-supported hospitals from 2005-2008 was 88 percent, Janisch-Hartline said. Prior to WNRP’s implementation, some participating hospitals had new graduate turnover rates that exceeded 50 percent.
Nurse replacement costs are reported to be equal to a nurse’s average annual salary, which is $62,140 for Wisconsin nurses according to the Bureau of Labor Statistics (2008). Therefore, if the residency program prevents at least one new graduate nurse from leaving the organization, the program becomes cost neutral, Janisch-Hartline said. The RWHC organizations typically pay the fee for participating nurses in their employment.
WNRP’s success has attracted attention from health care organizations facilities across the country. Marilyn Meyer Bratt, Assistant Professor at Marquette University and Project Director/Primary Investigator of the WNRP, has applied for an additional HRSA grant that will address the unique needs of newly licensed nurses practicing in rural hospitals. Building cultures to retain and advance role competency in rural nurses and coordinate dialogue on a national level to support rural nursing practice are the primary purposes of this proposal. To accomplish this, Bratt intends to develop partnerships with rural-based community and Critical Access Hospitals and health networks in Idaho, Illinois, Pennsylvania and Wisconsin. The grant will enable the delivery of a nurse residency program and other supportive services that are tailored to rural nursing practice.
For Deyo, WNRP has made all the difference. “I encourage everyone I know to go through this program,” Deyo said. “Something like this should be available for nurse graduates in all rural facilities. Being a rural nurse is a specialty in itself.”
Advanced Practice Nurses Fill Health Care Gaps in Rural Areas
by Candi Helseth
These days, Laura Thiem is the only “doc” in Adrian, Mo. But Thiem isn’t a physician—she’s a certified family nurse practitioner. Four years ago, after the local rural health clinic where she worked had closed, Thiem opened a primary care clinic on Main Street in Adrian, a town of 1,500 that she has called home for many years. Now Thiem sees and treats approximately 4,000 patients a year.
Ninety-three miles away, Marti Cowherd, who is certified as both a family and pediatric nurse practitioner, owns and operates the Family Practice of Ray County, a rural health clinic in Richmond, Mo., a city of about 6,000. When the physician who owned the clinic decided to leave Richmond in 2004, Cowherd purchased the practice.
“We serve a population of patients that probably wouldn’t have health care if I weren’t here,” Cowherd said. “On average, we see about 25 patients a day. Most of them are on Medicaid or Medicare. Or they have no insurance.”
Laura Thiem provides mental health and primary care services in her nurse-owned clinic in Adrian, Mo.
Managed care networks, changes in states’ health care practice laws, and lack of primary care physicians in rural areas are among factors that have contributed to an increase in nurse-owned and operated clinics. In every state, nurse practitioners are now allowed to prescribe medications, and in 13 states (and the District of Columbia) they can write prescriptions independent of physician involvement. Twenty-three states allow nurse practitioners to practice independently without physician collaboration or supervision, according to Polly Bednash, CEO of the American Association of Colleges of Nursing (AACN).
As primary care providers, Advanced Practice Registered Nurses (APRNs) can perform physical exams, diagnose and treat acute and chronic illnesses, provide immunizations, order X-ray and lab tests, and do other routine care similar to what is offered within the scope of a general physician practice. APRNs are among the growing population of registered nurses seeking advanced degrees and more responsibility. In 2008, 13.2 percent of the nation's registered nurses held either a master's or doctoral degree. Demand for nurses with advanced degrees far outstrips the supply, according to AACN.
Nurse practitioners offer primary care
At the University of Missouri-Columbia’s Sinclair School of Nursing, a nurse practitioner program is helping fill gaps in rural and underserved urban areas where primary care would otherwise be unavailable, said Shirley Farrah, Assistant Dean of Nursing Outreach. MU’s nurse practitioner program enables rural nurses to get advanced training through distance learning programs, completing the majority of their course work from the locations where they live. Farrah, who teaches a business component for nurses, said traditional nursing programs don’t prepare nurses for the business side of operating a practice.
“We currently have several nurse practitioners practicing in rural areas,” said Lila Pennington, a MU nursing professor. “Most of our nurse practitioners are settled in these areas and have family there. If you can educate people who live in the rural area and like living there, they are more likely to continue to live and work there.”
In its 2009 AMA Scope of Practice Data Series: Nurse Practitioners report, the American Medical Association argued that nurse practitioners and nurses with doctorate degrees do not offer care equivalent to that offered by licensed physicians.
But, Bednash said, “It does not take 11 years of a physician in medical school to competently immunize a child, treat an ear infection or sore throat, give a physical exam, or even manage diabetes or high blood pressure. APRNs provide this level of care and can be prepared at a much lower cost. An APRN will refer patients with complicated cases to a primary care or specialist physician in the same way that physicians refer complicated cases to specialists. Currently, the vast majority of APRNs are being prepared in master's and doctoral degree programs requiring three to four years of advanced education.”
Demand for doctors greater than supply
Nor is there an abundance of physicians to supply primary care needs, particularly in rural areas. Physician demand will outpace supply by 2025, according to a report, The Complexities of Physician Supply and Demand, issued by the Association of American Medical Colleges in November 2008. The report suggests that “non-physician clinicians such as physician assistants, nurse practitioners and others” can adequately provide some services “usually provided by physicians.”
Marti Cowherd, who owns and operates a rural health clinic in Richmond, Mo., says the satisfaction in her work comes from caring for multiple generations of patients.
While the majority of Cowherd’s medical practice consists of low-income, uninsured patients, the majority of Thiem’s patients have medical coverage. What the patients all have in common is that they live in a rural area where access to care would be almost non-existent if it weren’t for the nurse-owned clinics.
“I’m always busy,” said Thiem, who is also certified as a psychiatric mental health clinical nurse specialist. “I provide the medical home for these patients. I know the families and their medical history. A good portion of my practice is medical management for patients with chronic diseases. But I also spend a lot of time addressing mental health issues.”
According to Farrah, 80 to 90 percent of primary care issues seen in physician offices can be handled by nurse practitioners. Just as primary care physicians refer patients to specialists when patients need more care, nurse practitioners refer patients to physicians when a problem is outside the scope of the nurse practitioner’s practice, Farrah noted. Pennington added that numerous research studies have shown that in primary care settings, patient satisfaction and outcomes are at least equal to that of physician primary care.
“Like any family practice clinic, a lot of my time is spent seeing acute and chronic care needs—patients with diabetes, high blood pressure, cholesterol issues, kids with ear infections, colds, etc.,” Cowherd said. “I see everyone from premature babies to 97-year-old ladies. The satisfaction for me comes from caring for families, for generations of patients. I get to see and know the grandparents, grandkids, even great-grandkids and have the opportunity to take care of them when they’re sick and also when they’re well.”
Distance Technologies Help Rural Nurses Pursue Advanced Degrees
Demand in rural areas for registered nurses with advanced training will continue to increase, said Polly Bednash, CEO of the American Association of Colleges of Nursing (AACN).
“Fortunately for nurses already living in rural areas, more online programs are available to assist them in furthering their educations,” Bednash said. “Of the more than 630 RN-to-Baccalaureate programs available nationwide, at least 400 are offered partially online. These programs build on the education provided in diploma and associate degree programs and prepare graduates for a broader scope of practice.”
Many of the more than 160 RN-to-Master’s degree programs are also available through distance technologies.
Licensed Practical and Licensed Vocational Nurses
Licensed practical nurses (LPNs), or licensed vocational nurses (LVNs), care for people who are sick, injured, convalescent, or disabled under the direction of physicians and registered nurses. Most practical nursing training programs last about one year, and are offered by vocational and technical schools or community or junior colleges. LPNs must be licensed to practice.
Registered Nurses
Registered nurses (RNs), regardless of specialty or work setting, treat patients, educate patients and the public about various medical conditions, and provide advice and emotional support to patients' family members. Specific work responsibilities will vary from one RN to the next. An RN’s duties and title are often determined by their work setting or patient population served. RNs can specialize in one or more areas of patient care.
There are three typical educational paths to registered nursing—a bachelor's of science degree in nursing (BSN), an associate degree in nursing (ADN), and a diploma. BSN programs, offered by colleges and universities, take about four years to complete. ADN programs, offered by community and junior colleges, take about two to three years to complete. Diploma programs, administered in hospitals, last about three years.
Source: Occupational Outlook Handbook, 2010-11 Edition, Registered Nurses
Advanced Practice Nurses
There are four types of advanced practice nurses:
Clinical nurse specialists provide direct patient care and expert consultations in one of many nursing specialties, such as psychiatric-mental health.
Nurse anesthetists provide anesthesia and related care before and after surgical, therapeutic, diagnostic, and obstetrical procedures. They also provide pain management and emergency services, such as airway management.
Nurse-midwives provide primary care to women, including gynecological exams, family planning advice, prenatal care, assistance in labor and delivery, and neonatal care.
Nurse practitioners serve as primary and specialty care providers, providing a blend of nursing and healthcare services to patients and families.
Source: Occupational Outlook Handbook, 2010-11 Edition, Registered Nurses
The Rural Monitor is published by the Rural Assistance Center.
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