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NP PRACTICE

RURAL NP PRACTICE BARRIERS AND STRATEGIES FOR SUCCESS:

One State’s Story Linda L. Lindeke, PhD, RN, CNP Angela J. Jukkala, MS, RN

This study compares rural nurse practitioners’ (NPs’) descriptions of their practice over a 7-year period using three rounds of data collection with a similar instrument in one state. It offers a rare longitudinal glimpse of a state’s practice barriers over time. In 2003, the authors surveyed 55 NPs in Minnesota; they then compared those results with those obtained from 191 NPs in 2001 and 55 NPs in 1996. All three surveys used the same instrument; however, sampling criteria changed so that in 2003, only NPs residing in rural areas were contacted. (In previous rounds, all NPs in the state were contacted, and rural NPs were extracted using a selfreport of rural practice site criteria.) NPs in the 2003 survey rated their practice sites’ overall level of restrictiveness as “moderate,” which was similar to ratings in 1996 and 2001. NPs described many creative strategies—for example, the development of peer networks—that they used to improve their practices. Overall, rural NPs were thriving and feeling less isolated in 2003. Two particular areas of concern in 2003 were physicians’ resistance to the NP role, and low salaries for NPs in rural areas. Some described their workplaces as suboptimal and not supportive of the full NP scope of practice. Thus, although NPs have come a long way, at least in some areas of the United States, many still need to increase the public’s understanding of their role in the healthcare system.

R

ural residents’ access to health care is an urgent need in every state. In addition to access, rural residents require help in managing acute illnesses and chronic conditions, and in learning how to live more healthful lifestyles. NPs have provided safe, costeffective care to rural residents for more than 30 years in settings as diverse as clinics, hospitals, retirement communities, schools, workplaces, public health agencies, and peoples’ homes. They have also worked with community organizations to develop resources and systems of care at local and regional levels. Rural communities that employ NPs can increase residents’ access to care and improve their health outcomes. Rural dwellers have health challenges that differ from those of urban dwellers, including a shortage of primary care providers, an excess of aging citizens (many younger persons leave the “country” or farm to seek jobs in the

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city),1 and higher rates of uninsured individuals.2 Many rural clinics and hospitals struggle to maintain financial viability.3 In fact, 22 million rural Americans live in areas designated as Primary Care Health Professional Shortage areas.2 The term rural has many definitions.2 Most people think of the geographic dichotomy: a location is either urban (city) or rural (country). But others think more about population density or distance from a large urban area.3 Without shared definitions of what is rural, it is difficult to quantify rural health problems and make informed policy decisions.4 In this study, “rural” was defined by the zip code in Minnesota in which NP respondents worked. Overall, rural residents who receive NP-delivered health care are satisfied with their care.5 In addition, a survey of Montana hospital administrators showed that these employers were satisfied with the care rendered by NPs:6 75% stated that NPs increase services, and 100% found that hiring NPs was cost-effective. NPs are an asset to rural healthcare organizations that must compete in economically strained environments. However, many barriers still deter NPs’ success in rural settings. Barriers to practice include policies or circumstances that hinder NPs’ capacity to implement a full scope of practice. A 1996 study of the NP practice climate in rural Minnesota (n = 63) revealed that NPs’ education, responsibilities, and scope of practice were frequently misunderstood by physicians, nurses, and the general public.7 A 1997 survey found that 80% of rural Minnesota physician respondents were poorly informed about NP practice, specifically in terms of quality of care, autonomy, and reimbursement.8 Rural residents are placed at a disadvantage when NPs are unable to implement all their skills and deliver much-needed care. This research, which examined practice barriers over time in rural settings, can provide NPs and employers with strategies to succeed in configuring their practices. 12

Method Similar methodology was used on three occasions—1996, 2001, and 2003—to survey rural NPs in Minnesota, and the results were compared over the three phases of data collection. The Institutional Review Board of the University of Minnesota approved the study, and participants indicated informed consent by completing and returning the survey according to instructions outlined in the cover letter. Study Design—Information regarding respondents’ age, sex, and nursing education was collected in the first part of the survey. These demographic questions were followed by an instrument

Rural communities that employ NPs can increase residents’ access to care and improve their health outcomes.

with established content and face validity, the “Barriers to Practice Checklist.” This tool, originally developed for a national Division of Nursing study by the American Association of Colleges of Nursing, lists 28 practice barriers.9 Respondents checked off the barriers that they were facing at the time of the survey. They were not limited in the number of barriers that they could choose. Space on the questionnaire allowed them to specifically describe how each selected barrier restricted their practice. (Respondents were not asked to cite additional barriers beyond those included on the list, however.) Next, they rated the overall restrictiveness of their practice climate on a Likert-type scale (1 = very restrictive; 3 = moderately restrictive; and 5 = not

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restrictive at all). Based on results from the first phases, two additional openended questions were added to the Phase III study tool: 1. What have you or your employer done to advertise your NP role in your community, and have these efforts been successful? 2. If you had an unlimited budget, what would you do in your current practice site to improve your practice? Study Participants—In each phase of the study, NPs from the Minnesota Board of Nursing (MBN) database were invited to participate. By state law, in order to be included in the MBN database, NPs needed to be nationally certified in their advanced practice roles. In Phase I (1996) and Phase II (2001), all NPs in the MBN database were surveyed, with response rates of 50% and 55%, respectively. Respondents in these two phases self-classified their practices as “rural” or “urban”; the rural NPs were then extracted from the total sample for analysis (n = 63 in 1996; n = 191 in 2001). In Phase III (2003), a much more stringent definition of rural was used: Only NPs whose zip codes were in counties in categories 7, 8, or 9 of the Rural-Urban Settlement Continuum10 received questionnaires (n = 144). Seventy surveys were returned, 15 of which were unusable because the respondents worked in urban areas, were retired, had moved out of state, or did not complete the questionnaire. Therefore, 55 completed surveys were analyzed (response rate, 42.6%). Data Analysis—Data were analyzed using descriptive statistics. Investigators rank-ordered the barriers according to the frequency with which they were chosen by the NPs. Content analysis was applied to NPs’ written commentary regarding the barriers and the strategies that they used to overcome these barriers. Two nurse investigators independently read the comments, margin-coded the comments by topic, and then developed themes and extracted key phrases that illustrated the themes. The final themes were developed by consensus.


Limitations—These study findings cannot be generalized. They reflect practice in a single state with unique NP laws and regulations. Data were collected using self-reports, which entails the risk of possible bias from respondents providing socially desirable responses.

Results Most Phase III (2003) participants (mean age, 47 years) were family or adult NPs with master’s degrees. They resided in 26 rural counties in Minnesota, and represented a broad geographical distribution in the state. The mean rating for the overall restrictiveness of their practice environment was 3.6 (moderately restrictive) on the 5-point Likert scale. Barrier Frequency—In 2003, 9 barriers were selected by at least 20% of NPs (Table 1). Three barriers were not chosen by any respondent in the 2003 survey: (1) inability to practice because of legal restrictions; (2) inability to obtain malpractice insurance; and (3) inability to obtain a Drug Enforcement Agency number for prescribing. Several barrier frequency percentages were lower in 2003 than in either or both of the previous two phases (Table 2). For example, resistance from physicians declined from 38% in 1996 to 27% in 2001 but then rose to 35% in 2003. Lack of a peer network decreased from 51% in 1996 to 31% in both 2001 and

TABLE 2

TABLE 1

RURAL NP PRACTICE BARRIERS

BARRIERS CHOSEN BY ≥20% OF RESPONDENTS (N = 55) IN 2003

N (%)

Resistance from physicians

19 (35)

Lack of public knowledge of the NP role

18 (33)

Salary lower than that of other nursing positions

18 (33)

Lack of peer network

17 (31)

Limitations of space and/or facilities

16 (29)

Lack of third-party reimbursement legislation

14 (26)

Lack of positions for NPs

13 (24)

Incongruent expectations of others in one’s practice

13 (24)

Limitations of the types of services reimbursed

11 (20)

2003. Lack of public knowledge of the NP role remained steady at 41% in 1996 and 2001 but decreased to 33% in 2003. Barrier Descriptions—In addition to selecting barriers from the list that they were experiencing in their practice, respondents described them vividly in the questionnaire’s comment section. Content coding revealed a variety of issues affecting NP practice, which were grouped under two themes: (1) lack of workplace support and (2) consumer confusion about the NP role. Theme 1. Lack of workplace support. Being categorized as “mid-level providers” in their work settings result-

ed in some NPs receiving fewer vacation days and continuing education benefits, less desirable working space, and less support staff, when compared with their physician colleagues. Also, in some organizations, this mid-level status prevented NPs from gaining access to critical practice information. These comments exemplified this lack of workplace support: – NPs are experts, and provide the same care and management of difficult patients as do physicians, but for significantly less money, less support staff, less vacation time, and fewer benefits. – [There is] no mechanism in our

RANK ORDER COMPARISON OF TOP 5 RURAL NP PRACTICE BARRIERS OVER TIME

1996 (N = 63)

%

2001 (N = 191)

%

2003 (N = 55)

%

Lack of peer network

51

Lack of public knowledge of the NP role

41

Resistance from physicians

35

Lack of public knowledge of the NP role

41

Lack of understanding of the NP role by other health professionals

40

Lack of public knowledge of the NP role

33

Resistance from physicians

38

Salary lower than other nursing professionals

40

Salary lower than other nursing professionals

33

Problems with insurance reimbursement for services

37

Limited space and/or facilities

36

Lack of peer network

31

Lack of understanding of the NP role by other health professionals

32

Lack of peer network

31

Limitations of space and/or facilities

29

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clinic for NPs to be part of the administration system and I am not part of any department where [there are] regular meetings to communicate with peers and administration.

TABLE 3

SUCCESSFUL STRATEGIES FOR ADVERTISING THE NP ROLE

Newspaper columns, features

Ads showing NPs with patients

Some respondents felt that a lack of support from colleagues and administrators constrained their roles and limited their usefulness to the organization. Typical comments included:

Word-of-mouth advertising from patients

Clinic open-house events when new NPs are hired

Community seminars on health topics

NP guest appearances at club and church group meetings

– Hospital and clinical administrators are reluctant to expand NPs’ roles. – Other nurses (LPNs, RNs) have not worked with NPs before and are resistant to understanding all of the job functions. They do not always accept the functions I am legally able to perform.

Letters to or meetings with agencies on a regular basis to obtain referrals

Educating new receptionists about the NP role to facilitate positive

Some NPs described adverse effects when ancillary staff members were not supportive of their role: – My patient load decreases from 20 patients per day to 1 to 4 per day when a new receptionist starts. – Receptionists do not “offer” NPs…. [they] offer physicians first or will say, “Well, all we have left are openings with the NPs.” Theme 2. Consumer confusion about the NP role. Residents of some rural communities were unfamiliar with NPs. Patients’ confusion about the various providers’ roles limited their willingness to see NPs for care. Comments illustrating this theme included the following: – Being a new NP in my community is confusing to the public—they don’t know what they should see me for versus seeing an MD. – We have very few opportunities to practice in this area and rarely is there any autonomy as part of the role. We are pioneering in a decade [when NP practice] should be thriving. Success Strategies—In response to the open-ended question, ”What have you or your employer done to advertise 14

relationships ■

Formal marketing plan reaching regional treatment centers, hospitals, mental health agencies, law enforcement, social services, and public health agencies with NP-specific material

your NP role in your community, and have these efforts been successful?” NPs expressed many creative ideas regarding ways that they had successfully promoted themselves to the rural public (Table 3). Some used newspaper articles, newsletters, television ads, or brochures. One NP placed an ad on a billboard. Several NPs devised formal marketing plans, and met quarterly with other community providers and with representatives from law enforcement, public health, and social services. Others mailed annual brochures describing how NPs could meet the community’s various healthcare needs. Many NPs recommended attending community events (eg, health fairs, celebrations, educational seminars) to “spread the word.” A clever idea described by one NP was printing a description of her educational preparation and her role on the appointment cards given to her patients. Others had business cards that contained detailed information about their practice. Although advertising provided visibility for NPs, many respondents acknowledged that word-of-mouth publicity was the most effective way to increase their practice. Patients who told their family members and neighbors about their favorable experiences in receiving care from NPs were very pow-

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erful ambassadors. Typical comments included the following: – My best advertisement has been my patients. – I have heard [my patients] say, “I know she is not a doctor, but she is better than most of them and I will keep coming back to see her.” Wish List for Practice Improvement—In the second open-ended question, NPs were asked, “If you had an unlimited budget, what would you do in your current practice site to improve your practice?” Comments were extensive and creative (Table 4). Although many respondents had been advertising successfully, they wanted more intensive media campaigns (eg, advertising for several weeks in a row, 2-3 times per year; developing a clinic website). They also envisioned additional resources. Many NPs wished to hire staff to return phone calls, call pharmacies, schedule appointments with specialists, prepare patients for procedures, and send laboratory results and radiology reports to consultants. Some NPs wanted help in assigning patients to rooms and in checking routine vital signs, weight, and blood glucose levels. Others needed assistance in tracking charts and obtaining test results. The content of these wish lists seemed to indicate a lack


of support staff in some of these rural clinics; many of these activities could safely and appropriately be handled by employees with less educational preparation than that of NPs. Larger working quarters and improved physical facilities were on many NPs’ wish lists. They expressed their frustration about the lack of designated worksite space. They were hampered in their efficiency because of space constraints, and stated that this factor decreased their self-esteem. Equipment at rural practice sites was also not up to par. Respondents expressed a need for diagnostic and procedural equipment (eg, mammography, ultrasonography, radiography, modern laboratories). Others desired digital transmission capability for radiographic films so that the films could be read at a central location and the interpretations sent to the rural area. Basic equipment needs were described. For example, one NP stated that she wanted “enough equipment so that I do not have to move speculum lights from room to room.” Many diverse ideas were included in the wish lists. Some respondents wanted more professionals with additional training (eg, psychiatric NPs) so that they could expand the number of services rendered at the worksite. Others wished for funds for patient education materials. Still others wanted time to develop relationships with the consultants who provided specialty care to their patients. Patient transportation was an issue in some communities. Using technology such as telemedicine consultation to obtain expert opinions was recommended by some respondents. The NPs’ creativity in responding to this wish list question indicated commitment to their communities and a desire to obtain state-of-the-art facilities to meet their healthcare needs.

Discussion This research captured contextual descriptions of rural NP practice in a single state over time. The 2003 findings demonstrated how NPs implemented strategies that were successful in building their rural practices and gaining community acceptance for their roles.

TABLE 4

NP WISH LIST FOR PRACTICE IMPROVEMENT

Pay equity/salary increase

More advertising on scheduled basis

More support staff for phone calls, coordinating appointments, obtaining laboratory results

More patient teaching materials

Space specifically designated for NP use

More continuing education (reimbursement issues, computer use)

More on-site mental health staff (psychiatric NPs, social workers)

Pocket computers

More on-site NP colleagues

Time to visit specialists to see their practices first-hand

Hands-on clinical continuing education to enhance scope of practice with new skills

Transportation to enable patients to travel to clinics, hospitals, specialist appointments

Telemedicine for consultation, radiology

Expanded hours, services for indigent

NPs made a host of recommendations that they thought would improve their practices, given the hypothetical condition of unlimited resources. The issue of physician resistance, reported by 35% of respondents in 2003 (an increase from 28% in 2001), warrants some discussion. From an historic standpoint, physician resistance has existed since the inception of the NP role in 1965.11 It is an ongoing challenge for NPs and physicians to develop workplace relationships that are mutually beneficial and respectful of each profession’s knowledge and skills.12 Because many physicians are in leadership positions in healthcare organizations, they can be effective advocates for NP practice. Thus, NPs must work with physician leaders and clearly articulate what they bring to the healthcare arena, thereby allowing their role to be better understood and appreciated.12 Promoting a collegial and mutually respectful atmosphere appears to be an ongoing rural

practice issue in the state of Minnesota.13 Despite the success of marketing strategies, respondents desired even more resources and methods to publicize their roles to their rural communities. They described situations where their roles were not well understood by patients, even as the 40th anniversary of NP practice is being celebrated. These results confirm that issues described by Edmunds as far back as 1988 still persist.14 Edmunds suggested using both the media and political influence to

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increase NPs’ visibility; this recommendation is particularly applicable to NPs in Minnesota.

Implications for Further Research Barriers to rural NP practice still remain. In order to track and share strategies, as well as document trends, ongoing research is needed. Posing open-ended, hypothetical questions such as those used in this study can be revealing and can stimulate creative ideas. Further work is also needed to determine effective ways to educate the public and other healthcare professionals about the NP role. Examining ways to develop and maintain peer networks for rural NPs would be beneficial. Another area of research might involve the study of Internet utilization for continuing education programs and long-distance problem-solving between geographically isolated NPs. Strategies for mentoring rural NPs is also a topic for further research. Linda L. Lindeke is a practicing pediatric nurse practitioner. She is an associate professor and Angela J. Jukkala is a doctoral student, both at the University of Minnesota School of Nursing in Minneapolis.

Acknowledgments This research received funding in 2001 and 2003 from the Collaborative Rural Nurse Practitioner Project, which was supported by the Minnesota Office of Rural Health and Primary Care. The Minnesota Nurses Association Foundation partially funded the 1996 and 2001 studies, and the Minnesota Board of Nursing provided the subject database for all three studies.

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Promoting a collegial and mutually respectful atmosphere appears to be an ongoing rural practice issue in the state of Minnesota. Mary Tanner, PhD, RN, was co-principal investigator of the 1996 and 2001 studies and made significant contributions to this work.

References 1. National Rural Health Association. Access to health care for the uninsured in rural and frontier America; 1999. Available at: www.nrharural.org/dc/ issuepapers/ipaper15.html 2. Rural Information Center Defining rural: available resources; 2002. Previously available at: www.nal.usda. gov/ric/faqs/ruralfaq/htm 3. Moscovice I, Stensland J. Rural hospitals: trends, challenges, and a future research and policy analysis agenda. J Rural Health. 2002;18(S):197-210. 4. Hewitt M. Defining rural areas: impact on health care policy and research. Staff paper, Office of Technology Assessment. Washington DC: US Government Printing Office; 1989. 5. Knudtson N. Patient satisfaction with nurse practitioner service in a rural

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setting. J Am Acad Nurse Pract. 2000; 12(10):405-412. 6. Larsson LS, Zulkowski K. Utilization and scope of practice of nurse practitioners and physician assistants in Montana. J Am Acad Nurse Pract. 2002; 14(4):185-190. 7. Lindeke LL, Bly T, Wilcox R. Perceived barriers to rural nurse practitioner practice. Clin Excell Nurse Pract. 2001;5(4):218-221. 8. Bergerson J, Cash R, Boulger J, Bergerson D. The attitudes of rural Minnesota family physicians toward nurse practitioners and physicians assistants. J Rural Health. 1997;13:196-205. 9. Washington Consulting Group. Survey of Certified Nurse Practitioners and Clinical Nurse Specialists: December 1992. Rockville, Md: Division of Nursing, Health Resources and Services Administration; 1994. 10. Economic Research Service. Measuring rurality: rural-urban continuum codes. United States Department of Agriculture; 1993. Available at: www.ers. usda.gov/briefing/rurality/RuralUrbCon/ 11. MacDonald J, Katz A. Physicians’ perceptions of nurse practitioners. Can Nurse. 2002;98(7):28-31. 12. Lindeke LL, Block DE. Interdisciplinary collaboration in the 21st century. Minn Med. 2001;84(6):42-45. 13. Phillips RL, Harper DC, Wakefield M, et al. Can nurse practitioners and physicians beat parochialism into plowshares? A collaborative health care workforce could improve patient outcomes. Health Affairs. 2002;21(5):133-142. 14. Edmunds MW. Promoting visibility for the nurse practitioner role. Nurse Pract. 1988;13(3):53-55.


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