Rural Health Care: Challenges in Advanced Practice Nursing Charles Anstett, RN, CHPN University of Southern Indiana 2006
“In rural practice you get the whole family and the whole life, not pieces and parts.”Trossman, S. (2001). Fueling two passions: NP role, ruralnursing. American Nurse, 33(4): 19. “I can have a newborn one minute and a 100-year-old the next.”Trossman, (2001).
Woman to Woman The Woman to Woman project provided a nursing research-based model for conducting support groups, fostering self-care, and providing health education, via personal computers, to isolated, chronically ill, rural women. Of special interest to researchers is the lack of social support for women suffering chronic illness in isolated, rural areas. Sullivan, T., Weinert, C., Cudney, S. (2003) Management of chronic illness: voices of rural women. Journal of Advanced Nursing, 44(6): 566-74. In 2003 the World Health Organization cautioned that a shift from acute care to long-term care models will be necessary to accommodate the increasing burden of chronic diseases. The authors of this study point out that this burden is disproportionately borne by vulnerable populations, and chose to study its impact on rural women.
Findings of the Woman to Woman Project The women’s use of humor (161 instances) far outdistanced all other subcategories, indicating its importance in helping them manage their day-to-day challenges of living with chronic illness. The impact of physical symptoms on their quality of life was reflected in the number of times they cited fatigue/sleepdisturbance (119) and pain (92) in their exchanges. Depression was the primary emotion they experienced (50), along with fear (26). Sullivan, Weinert & Cudney, (2003).
Barriers to Effective Practice Those considering careers as rural NPs need to be proactive, anticipating barriers to practice and networking with other providers. Lindeke, L., Grabau, A., Jukkala, A. (2004). Rural NP perceptions of barriers to Practice. The Nurse Practitioner, 29(8): 50-1. In addition, a strong advocacy role needs to be assumed in order to influence policies on difficult issues such as prescribing privileges and reimbursement.
The thriving category elicited the greatest number of comments from NPs, most of which related to nurses’, physicians’, and the general public’s lack of knowledge about NP education, roles, and competence. (Lindeke, Grabau & Jukkala, 2004).
Satisfaction! A research study completed in 2000 indicated a high level of patient satisfaction with the service provided by rural nurse practitioners. Knudtson, N. (2000). Patient satisfaction with nurse practitioner’s services in a rural setting. Journal of the American Academy of Nurse Practitioners, 12, 405-412.
Recruitment Incentives The need for primary care providers willing to work in rural America remains very high. Programs which offer financial incentives such as student loan repayments, housing and travel expenses, bonuses and retirement plans have a marked effect on rural NP placement and retention. Kippenbrock, T., Stacy, A., Gilbert-Palmer, D. (2004). Educational strategies to enhance placement and retention of nurse practitioners in rural Arkansas. Journal of the American Academy of Nurse Practitioners, 16(3): 139-143.
Challenges After spending considerable time searching literature, reading journal articles and visiting web sites it has become clear to me that anyone considering a career as a rural nurse practitioner must to prepare for a number of serious challenges.
Independence vs Isolation In addition to being the primary health provider in many rural communities, there may also be limited access to doctors or other practitioners for the rural NP to seek out for advice. (Trossman, 2001).
Barriers Barriers to effectively practicing as an NP may be limited to simple logistical issues such as finding adequate office space. On the other hand, in some parts of the country a lack of understanding of the NP practice role still exists. One’s practice may be seriously affected by restrictive prescription and reimbursement regulations, ironically, hindering access to primary care for the very population the NP has been hired to serve (Lindeke, Grabau & Jukkala, 2004).
Ideally Suited for the Job The challenges facing rural NPs require forethought, imagination and a great deal of patience to overcome. But for the nurse who is outgoing and thrives on independence, this could very well be an ideal practice environment!
Final Thoughts My own personal fascination with the outdoors, simple living and the rapidly fading rural landscape of our country has led me to seriously consider the rural NP career path. Although the challenges discovered during this project did make the NP job appear much more complicated, they also had the effect of making the job sound more rewarding.