- B. Trimble
Perceptions of nurse practitioner students on clinical rotations in rural health care areas, and the likelihood of practicing in a rural area.
With the current primary care provider shortages in rural areas, could the key be the use of nurse practitioners, to ultimately, fill the gap in medical services? How satisfied are patients with a nurse practitioner’s services? How do communities recruit and keep nurse practitioners? What role do rural clinical rotations play in the recruitment of nurse practitioner graduates for practice in rural areas?
Rural communities have difficulty recruiting and retaining primary care providers. With the number of aging providers looking at retirement and the lack of medical school graduates interested in primary care, the need will be further increased. The national shortage of primary care providers has many communities searching for help. Meeting the current needs is difficult and the need for services is expected to increase as the rural population ages and the enactment of the patient protection and affordable care act. Advanced practice registered nurses, whom studies show can provide care that is safe and as effective as a physician, are a powerful solution to the problem of the shortage in primary care providers and rising health care costs. There are currently 189,000 nurse practitioners, 35,000 nurse anesthetist, and 18,500 certified nurse-midwives in the United States according to the American Association of Nurse Practitioners (American Association of Nurse Practitioners, 2014).
Nurse practitioners play a pivotal role in providing necessary medical care to the underserved of rural communities. A need for studies that examine the experiences of rural health care providers, to assess the barriers and the facilitators for nurse practitioner practice are needed. Offering mentorships, in the rural areas, may be another way to increase interest of the nurse practitioners in rural areas. As the new health care laws become effective, the need will increase. The purpose of this study is to examine how incorporating rural health rotations, in training of nurse practitioner students, may improve on the recruitment of nurse practitioner graduates into the rural healthcare sector.
In rural health centers, nurse practitioners fill key leadership positions. In a study on rural health clinic efficiency and the impacts made by nurse practitioners and physician assistants, indicated that rural health centers that used nurse practitioners had a high rate for expertise in quality care and cost effectiveness (Ortiz, Wan, Meemon, Paeth, & & Agiro, 2010).
The purpose of the study was to investigate the impact of nurse practitioners to rural health clinics yield, determine the association of proficiency indicators, and understand specific and organizational factors that affect productivity. The questions posed were as follows: Does rural health clinic’s performance vary contingent on nurse practitioner staffing? To what extent do nurse practitioners influence productivity? What are characteristics of highly productive rural health clinics? (Ortiz, Wan, Meemon, Paeth, & & Agiro, 2010).
. The study suggests that, employments of higher portions of nurse practitioners has a definite stance on productivity, and are able to handle a larger number of patients without adding professional staff. Process efficiency in clinics with a large percent of licensed staff tends to use larger numbers of nurse practitioners. Clinic size is definitely associated with industrial efficiency. The larger the clinic’s professional percentage, the higher the efficiency or production observed. The clinics able to maximize the value of nurse practitioners are the most cost effective in providing health care amenities.
The conclusion of the study was that the use of nurse practitioners and physician assistants increased productivity and cost effectiveness in clinics that maximized the use of these medical professionals. There is a need for further studies to determine the contribution of nurse practitioners. Future research would involve risk adjustment factors to assess the effects of patient demographics and socioeconomic aspects. In addition, the evaluation of observational information would provide a better understanding of the nurse practitioner involvments. (Ortiz, Wan, Meemon, Paeth, & & Agiro, 2010).
In a study conducted by Ryan and Rahman in urgent care centers, to determine what factors influence the satisfaction of care provided by nurse practitioners, it was determined that the care provided was scored positive. The scores were higher for those noted to be uninsured as compared to those with insurance.
A descriptive study including four urgent care centers using two to four nurse practitioners was used for the study. Two of the four urgent care centers were excluded from the study, due to weather conditions. Patients were asked to complete a post visit review and sealed in an envelope after completion. Participant inclusion was they had to be 18 years of age, be able to read, write and comprehend English. The survey contained five questions on demographics and thirteen items where ten assessed the clarity of the nurse practitioner role. Approval was granted from Shenandoah University IRB and the four participating urgent care centers. No enhancements were offered to participants for participation in the study.
Examining factors that affect patient satisfaction, with nurse practitioners in rural urgent care centers studies showed that there was a high rate of patient satisfaction regardless of age, insurance, race, or gender. The clarity of the nurse practitioner role was significantly different between participants that were uninsured as compared to those with insurance. The uninsured rated the experience higher than those with insurance. The overall scores for satisfaction with care were positive. Several of the patients were unaware they were being treated by nurse practitioners until the after treatment survey. This implies that the care was comparable to what had been provided by physicians in the past. The American healthcare system has not been able to meet the demands for accessible, low-cost medical care. Rural areas face a shortage of healthcare providers as family physicians retire and current graduate physicians decide to enter into specialties rather than general practice. Nurse practitioners can fill the gap in medical providers. The role of the nurse practitioner is on the increase in rural areas that are underserved and are well accepted by colleagues and patients. Nurse practitioners provide competent care; this and previous studies have confirmed that patients are highly satisfied with primary care provided by nurse practitioners (Ryan, 2012).
In a qualitative study by Boynton Sharp, to explore the factors related to the recruitment and retaining of nurse practitioners in rural areas, it was determined that nurse practitioners are more likely to accept a position in rural healthcare after having completed at least one clinical practicum in a rural setting (Boynton Sharp, 2010).
In this study, the sample size was 29 nurse practitioners from across the United States. The data collection method was semi-structured interviews. Analysis of categories and themes determined that three of the concepts of rural nursing theory were applicable. It was anticipated that the knowledge gained would contribute to understanding nurse practitioner choices to practice in rural areas, to determine the developing rural nurse practitioner educational programs and existing federal agencies involved in recruiting and retainment nurse practitioners, in rural areas.
A qualitative study using a focused ethnographic approach was used to explore the cultural construction of rural nurse practitioner roles. A conceptual model analysis from the theory of cultural marginality was developed. The marginality framework was developed to provide a basis for data collection and analysis. Data set used interviews conducted using audio/video tapes of electronic media interviews through web conferencing, except two interviews were conducted by telephone. Data analysis was through transcription of interviews; at the end of the analysis three concepts from the rural nursing theory were identified. Lack of anonymity was subdivided into respect and annoyance. Outsider versus insider status was defined, not as being an insider in the community, but as an outsider in the medical community.
Permission to conduct the study was granted by the University of Texas at El Paso’s IRB. Names of participants did not appear anywhere in the report or research.
This study identified the three concepts of the rural nursing theory. In the study, the nurse practitioners did not find the lack of anonymity to be an annoyance, but viewed it as a part of being an effective medical care provider. The study indicated that nurse practitioners are well accepted by the community members. However, nurse practitioners are not always accepted by the existing medical community. Self-reliance was indicated by the nurse practitioner’s ability to function alone and make independent decisions related to their clinical practice.
Due to differences between urban and rural care needs, it is important that nurse practitioner students be given an appreciation for the uniqueness and benefits of rural practice including a) limited access to healthcare, b) limited resources, and c) distance to specialists. This can be accomplished through changes in didactic and clinical components of nurse practitioner educational programs.
Nurse practitioners who accept positions in rural areas most often have a background in rural areas, have participated in a rural training program, or have a desire to serve in a rural community. Completion of a rural program is associated with accepting a position in a rural practice. In this study, 72% of the nurse practitioners completed at least one rural clinical practicum. This supports the importance of rural training as an effective strategy in recruitment of nurse practitioners for rural areas (Boynton Sharp, 2010).
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In another study published by Purdue University (Richards, 2011) stated that as practitioner students are subjected to underserved populations, they are able to better understand the complicated clinical situation, which also confronts nurse practitioners to provide valuable and professional, high quality safe and cost efficient patient care. The practitioner students rotated through the clinics; this was found to improve the staff role in clinical knowledge, strengthen the evidence of clinically relevant research, and enhance the classroom instructions and assignments. The rotations made class instruction and assignments more meaningful when the students observed the instruction being used in a clinical setting. The experience integrated previous subject matter and allowed practitioner students to develop skills in a supportive and strengthened environment. Allowing students to perform alongside nurse practitioners, help to develop mentoring and educational relationships, regard for others capability, and improves comprehension of the nurse practitioner role. The staff roles shifted from the expert to a mutually supportive learning association (Richards, 2011).
The advanced practice nurse can serve to fill the gap in primary health care. Nurse practitioners can provide quality, cost effective care to these communities, offsetting the limited access and rising health care costs. Access to primary health care is essential in maintaining and improving health. Those who have regular primary health care receive more preventative services, are more likely to comply with prescribed treatments, and have lower rates of illness and preventive deaths. To ensure recruitment and retainment of nurse practitioners in these areas, it is important to increase the nurse practitioner student experience with clinical rotations in rural or underserved areas.
American Association of Nurse Practitioners. (2014). NP Fact Sheet. Retrieved from AANP.org: http://www.aanp.org/all-about-nps/np-fact-sheet
Boynton Sharp, D. M. (2010). Factors related to the recruitment and retention of nurse practitioners in rural areas. (3409167), 110. Ann Arbor, Mi, United States: ProQuest, LLC. Retrieved March 29, 2014, from http://search.proquest.com.southuniversity.libproxy.edmc.edu/docview/613695577?accountid=87314
Ortiz, J., Wan, T., Meemon, N., Paeth, S., & & Agiro, A. (2010, July/August). Contextual Correlates of Rural Health Clinics’ Efficiency: Analysis of Nurse Practitioners Contributions. Journal for Health Care Leaders, 28(4), 237-44. Retrieved March 20, 2014, from http://www.medscape.com/viewarticle/729490_1
Richards, E. (2011). The role of nursing students at two rural nurse managed health clinics. School of Nursing Faculty Publications (paper 4). Purdue University. Doi:10.1080/07370016.2011.539086
Ryan, K. D.-C. (2012, February 1). Examining Factors Influencing Patient Satisfaction With Nurse Practitioners in Rural Urgent Care Centers. Journal of American Academy of Nurse Practitioners, 24(2), 77-81. Doi:10.1111/j.1745.7599.2011.00688.x
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