The Rural Nurse Practitioner: A Challenge and a Response

The Rural Nurse Practitioner: A Challenge and a Response JUDITH A. SULLIVAN, RN, EDD, CHRISTY Z. DACHELET, MS, HARRY A. SULTZ, DDS, MPH, AND MARIE HENRY, RN, DNS Abstract: From a cohort of 525 employed nurse practitioners (NPs) who graduated between May 1975 and June 1976, 85 (16 per cent) reported practicing in rural areas. While 91 per cent of the rural NPs chose the short-term certificate programs rather than the master's degree for their NP preparation, 47 per cent had already earned a baccalaureate or master's degree prior to NP training. Family NPs comprised the most frequent specialty area chosen, followed by pediatric and adult specialties. Of the 85, 99 per cent were actually providing a broad array of primary care services to clients over a wide age range. Physicians were peri- odically available on site in about 80 per cent of the practices, by telephone in 97 per cent of the practices, and in 60 per cent of the practices provided additional consultation by record review. Major motivations of the NPs for entering rural practice were to participate in a creative approach to health care delivery (50 per cent of the practice settings were less than five years old), and for the opportunity for role autonomy. Over 95 per cent of these NPs and employers were satisfied with the NP role. (Am J Public Health 68:972-976, 1978.) Introduction Rural communities have gradually been losing primary care providers as retiring family physicians were not replaced. Nurse practitioners have been prepared for the past ten years to extend their services into the primary care field, and to bring with this new preparation their skills in health teaching and counseling. Thus, a new type of health care provider is available to communities to help them meet their primary health care needs. In the rural areas, infant mortality rates are among the highest in the nation, and there are proportionately twice as many chronically disabled persons.' Nurse practitioners have shown the ability and interest to manage programs of prevention, common health problems, and chronic illness conditions, including the psychosocial aspects of treatment.2 The new Rural Health Bill3 enables nurse practitioners to be reimbursed for services directly to clients, thus for the first time paving the way for health care to reach clients who could not travel to see a doctor. While the numbers of NPs have been growing steadily for the past ten years, this study represents an attempt to describe a cross-section of a national one-year graduating cohort, their training, and practice. In the light of these changes, data related to rural practice were sought from a national longitudinal cohort study of From the University of Rochester School of Nursing. Address reprint requests to Judith A. Sullivan, RN, EdD, Community Health Nursing, University of Rochester School of Nursing, 601 Elmwood Avenue, Rochester, NY 14642. This paper, submitted to the Journal October 25, 1977, was revised and accepted for publication February 21, 1978. 972 over 1,000 nurse practitioners,* conducted by Sultz, et al.4 In this paper, we will describe: 1) the characteristics of the rural nurse practitioners; 2) the characteristics of their practice; 3) availability and motivation of NPs for rural practice; 4) employment conditions of the NP; and, 5) the satisfaction of both NP and employer with the NP role. The Study Population A cohort of 1,099 nurse practitioners graduating between May 1975 and June 1976 were surveyed while in their programs, and 69 per cent were successfully resurveyed one year after graduation. Of these, 532 were employed as NPs and, of the 525 answering the question on location of practice, 85 (16 per cent) reported they were in rural locations. The remaining 440 (84 per cent) variously described their practice locations as inner city, other urban, suburban, military, industrial, college, hospital, and Indian reservation. Demographic, Educational, and Experiential Description of the Rural NPs The nurse practitioner group as a whole did not appear different in demographic characteristics from their urban counterparts. The modal age range for both rural and other NPs was 25-34 years, comprising over 50 per cent of the NPs *This study was carried out in 1976 under a contract from the Division of Nursing, Department of Health, Education, and Welfare. AJPH October, 1978, Vol. 68, No. 10

TABLE 1 Type of NP Program by SULLIVAN, ET AL. TABLE 2-Specialty Selected by Rural Non-Rural Type of NP Practitioners Practitioners Total Per Cent* Program (N = 85) (N = 440) (N = 525) Certificate 91 76 78 Master's Degree 9 24 22 TOTAL 100 100 100 Chi Square P < 0.01 *Four NPs completing certificate programs and three NPs completing master's programs did not supply information on practice location. Rural Non-Rural Specialty Practitioners Practitioners Total Per Cent* Selected (N = 85) (N = 440) (N = 525) Family 39 27 29 Pediatric 32 36 35 Adult 21 22 22 Maternity 5 6 6 Midwifery 2 9 8 Psychiatric 1 1 1 TOTAL 100 100 100 Chi Square p = NS in all practice locations. Over 97 per cent were female, and over 95 per cent were caucasian, reflecting the current trends in the nursing profession in general. A slightly greater per cent of rural NPs were unmarried: 52 per cent compared with 44 per cent of the non-rural NPs. Educational preparation of NPs has taken two forms. Nurses may be prepared either through short-term continuing education (certificate) programs or through master's programs that included NP content and practice. A higher proportion of rural NPs (91 per cent) than urban NPs (76 per cent) attended certificate programs. The remainder in each group received master's degrees (see Table 1). Although a high percentage of rural NPs enrolled in the non-degree programs, 47 per cent already had earned a baccalaureate or master's degree prior to their NP training. The remaining 53 per cent held hospital diplomas in nursing, or the associate degree. The average number of years of prior employment in nursing was less than ten years, and did not vary by setting. Practice Characteristics Among all NPs educated for primary care in rural areas, 99 per cent indicated that they were providing primary care to clients in their practice settings. Considering the fact that 44 per cent of these nurses returned to their former settings where they were often expected to resume portions of their former duties, a high percentage of time in primary care activities was provided by this group. Over two-thirds of the rural NPs, as compared to 60 per cent of the non-rural NPs, spent 100 per cent of their time functioning in their new extended role. An additional 20 per cent in each type of practice location spent over half their time in primary care practice. In terms of program specialty area, the non-rural group did not vary appreciably from the rural group, except for the higher proportion of those with the family specialty in the rural areas (see Table 2). The NPs were asked to indicate the types of health care they were actually providing for the several age groups of the population. Overall, more NPs in rural practice reported that they worked in settings providing a broad range of services to all age groups than was reported in the non-rural group, although the differences were not large. Within the rural group regardless of specialty, an average of 92 per cent of the NPs worked in practices providing health assessments for clients; 93 per cent provided care for physical illnesses; 81 per cent provided care for emotional or mental health problems; 82 per cent provided family planning assistance; 79 per cent provided maternity care; and 81 per cent provided emergency care. In terms of patients seen per day, the majority of rural NPs (79 per cent) saw on average between 6-15 patients; in two practices the NPs saw more than 21 patients per day. Because the patients per day were averaged over the nurses' work week, and only two-thirds were providing primary care 100 per cent of the time, the patients per day figures may be low. Further study is needed to reflect accurately the number of patients seen per primary care session. In these rural settings, 62 per cent of the NPs reported that physicians were "sometimes" present, and 20 per cent reported having a physician present "seldom" or "never." By inference, it appears that the NPs themselves are offering much of the direct services to clients that they claim are offered in their practice settings. Collaboration with physicians, however, is arranged when needed. In practice settings without physicians on-site, 97 per cent reported that a physician was available "always" or "usually" by telephone. Further, about 60 per cent of the rural NPs indicated that the physician "always" or "usually" reviewed their management of client problems by record consultation. Availability and Motivations ofnps for Rural Practice The geographic distribution of NPs across the United States is fairly even in both rural and non-rural settings (see Table 3). In the south and west, where the greatest proportion of the rural population resides, the greatest percentage of the rural NPs are practicing. In the aggregate, however, it AJPH October, 1978, Vol. 68, No. 10 973

THE RURAL NURSE PRACTITIONER TABLE 3-Region* of the United States by Location of Practice Setting Rural Non-Rural Practitioners Practitioners Region (N = 85) (N = 438**) South 20 80 West 28 82 Midwest 14 86 Northeast 13 87 Average Per Cent 16 84 *Regions as designated by the National League for Nursing **Two NPs from non-rural areas did not provide information on region of United States is estimated that 25 per cent of the population lives in rural areas, and the finding that only 16 per cent of this cohort of NPs entered rural practice suggests there is a need for attention to distribution. Among a list of 12 possible reasons for selecting a practice setting, each NP was asked to identify the most important reason for the selection. The two reasons comprising 65 per cent of the responses were: "the setting offered a creative approach to health care delivery," and "the opportunity for role autonomy." The location of employment as a prime concern was reported by only 10 per cent of the rural NPs and 9 per cent of the non-rural NPs (see Table 4). The fourth highest reason, selected by only 5 per cent of the rural NPs and 10 per cent of the non-rural NPs, was "training and educational opportunity," indicating that learning for itself was TABLE 4-NP's Most Important Reason for Choosing Present Position by NP's Most Important Reason for Rural Non-Rural Average Choosing Present Practitioners Practitioners Per Cent Position (N = 80) (N = 420) (N = 500*) Setting offers creative approach to health care delivery 40 23 25 Role Autonomy 25 29 29 Location of employment 10 9 9 Training/educational opportunities 5 10 9 All remaining reasons** 20 30 28 Total Per Cent 100 100 100 Chi Square P < 0.02 *Five NPs completing certificate programs and twenty NPs completing master's degree programs did not supply information on most important reason for choosing present position. **Of the eight remaining reasons, no one reason was cited by more than 7 per cent of the NPs. These reasons were: only job available, good salary/fringe benefits, opportunity for advancement, prestige work that is related to social problems, job security, availability of medical collaboration, and opportunity to teach in an NP program. 974 not enough of a motivation for most NPs, but that their reasons were largely tied to anticipated practice opportunities. In comparison with the non-rural NPs, a significantly greater number of rural NPs selected as their reason "setting offers a creative approach to health care delivery." This suggests that a major recruitment factor might be the flexibility and creativity allowed in rural practice settings. Further, it suggests a direction that should be considered in the attraction of health workers to any setting-urban or rural. Employment Conditions Location: The majority of NPs (71 per cent) in rural settings reported that they were practicing in a communitybased health center or clinic, or in a private practice. In comparison, the non-rural NPs were more evenly distributed among a wide variety of practice settings, reflecting the array of employment settings available in these areas. Interestingly, a high proportion of the nurses going into primary care practice were formerly from hospital inpatient settings. As expected, community health agencies, health centers, and especially in rural areas, private physician's offices were also former employment settings of large numbers of these nurses. Duration ofpractice: Fifty per cent of the rural NPs reported entering practice settings that had been providing patient care for less than five years, whereas for NPs entering non-rural practice, only 35 per cent of the practice settings were less than five years old. Further, 43 per cent (as opposed to 23 per cent in non-rural settings) reported that the position of nurse practitioner had been planned from the beginning in the practice setting being reported. These factors seem to support the assertion that the rural practice settings offered more opportunity for creative approaches and role autonomy for the NP than did the non-rural practice settings, where these factors were quite different. Salary: The average annual salary of this cohort of rural NPs was $12,200. This represents an increase of about $2,000 over the salary prior to NP training. In comparison, the non-rural NP's mean salary was $13,400. Of the 20 per cent of all NPs earning over $16,000 annually, over 95 per cent were from non-rural areas. The extent to which the salary reflects the difference in credential (master's degree vs. certificate) or the population density was not determined. Employers: The employer was likely to be a physician in over two-thirds of the rural practice situations. Next most likely employers were administrators, other nurses, or nurse practitioners. In a separate questionnaire, 414 employers (80 per cent) responded to questions related to their NP employee. They were asked to give their impressions of changes which had occurred in the practice in conjunction with the hiring of the NP. Employers in rural areas cited more changes than did employers from non-rural areas. The specific changes cited by over 20 per cent of the rural employers included: change in the pattern of the flow of patients through the practice (47 per cent); change in the physical plant (remodeling, expansion, relocation) (31 per cent); addition of new practice units, such as a satellite clinic AJPH October, 1978, Vol. 68, No. 10

TABLE 5-Employer's Most Important Reasons and Most Significant Effect of Employing the NP by Type of Contribution to the Practice Employer's Response* Percentage of Most Important Percentage of Most Significant Reason for Employing NP Effect of Employing NP Contribution of NP to Practice* (N: 65)** (N: 67)** To extend services to more persons 52 57 Improvement in quality 45 40 To cope with existing practice 3 3 TOTAL 100 100 *Includes sub-categories developed to accommodate responses to open-ended items. "Three employers did not provide data on most important reason, and one employer did not respond to the most important results. SULLIVAN, ET AL. (34 per cent); and extension of office hours (22 per cent). By comparison, only one type of change in the practice was cited by more than 20 per cent of the employers in non-rural settings, that being a change in the flow pattern of patients through the setting. This finding suggests that more flexibility, more amenability to change, exists in rural practice. In agreement with this finding, as noted earlier, the primary motivation of the largest number of rural NPs was the opportunity for more flexibility and a creative approach to health care delivery. Satisfaction ofnps and Their Employers The eventual success of any initiatives to attract and keep nurse practitioners in underserved rural areas is likely to be a function of the job satisfaction realized by the NP, the satisfaction of the employer with the NP, and the acceptance of the NP by other providers and patients. The NPs were asked to indicate their degree of satisfaction on 12 specific aspects of ther position,* as well as to give an overall satisfaction rating. Overall, 74 per cent of the rural NPs described themselves as "very satisfied," and an additional 20 per cent said they were "somewhat satisfied" with their present positions. These percentages were slightly higher than for the non-rural NPs, indicating a slightly greater contentment with practice in the rural areas. Employers reported marked satisfaction with the nurse practitioner. Over 97 per cent of the employers of NPs in both rural and non-rural settings indicated they were either "very satisfied" or "somewhat satisfied" with the NP in their employ. This high degree of satisfaction might be explained in part when one compares the data on the employers' most important reason for hiring the NP with the em- *These aspects were: type of patient served, pay and benefits, administrative climate within the setting, location of the job, variety of activities required, emotional demands of the job, proportion of time spent on non-professional tasks, amount of work required, availability of facilities, back-up necessary to provide good patient care, preparation for the tasks assigned, and the type of assignment in relation to level of ability. ployers' assessment of the most significant effect of employing the NP. Employers in rural settings reported that their most important reason for hiring the NP was "to extend services to more persons." This factor proved to be the most significant effect realized in the rural practices (see Table 5). By comparison, employers in non-rural locations both sought the NPs' services primarily to improve the quality of care provided, and found this to be the most significant effect realized from the hiring of the NPs. Further, over 90 per cent of both the NPs and employers reported NPs to be "well accepted" by other health professionals, administration, clinical staff, and by the patients. Summary and Discussion Programs preparing nurse practitioners for rural as well as urban practice have been gradually gaining momentum over the past ten years. From this survey of a one-year national cohort of NPs and their employers, those who described their practice settings as rural were selected for discussion in this paper. Data such as these, while limited to this particular cohort, are useful as a basis for projecting the impact this movement will make on the nation, particularly with the passing of enabling legislation such as the Rural Health Bill. The fact that in only one year 85 nurse practitioner graduates reported entering primary care practice in rural areas is indicative of the potential in the number of new primary health care personnel that could be mobilized in a short time. Of the numbers prepared for primary care practice, over 99 per cent report providing such care, even though 44 per cent have returned to their former practice locations where they had other duties. The majority see between 8 and 15 patients per day-a reasonable volume to expect a high quality of service. Further, these nurse practitioners are providing a wide array of health services that are well accepted by the majority of employers, physicians, and patients alike with whom they are in contact. The geographic distribution of the rural NPs is about even across the United States, with slightly higher percent- AJPH October, 1978, Vol. 68, No. 10 975

THE RURAL NURSE PRACTITIONER ages in the south and midwest where more rural communities exist. The primary reasons the majority of the nurses gave for their motivation to enter their particular practice settings were that "the setting offered a creative approach to health care delivery," and "the opportunity existed for role autonomy." In fact, the descriptions of their practice sites bear this out in that one-half of the sites were not more than five years old; 43 per cent had been planned with the expectation of hiring an NP from the beginning; and over onehalf reported specific changes in the setting since the arrival of the NP. Among the rewards of rural practice for NPs are a higher salary from a prior position (although still below that in non-rural settings), a challenging job, and a high level of satisfaction in general for themselves, their employers, and the patients. REFERENCES 1. Ross MH: Rural health care-is prepayment a solution. Public Health Rep. 90:298-302, 1975. 2. Kirk RFH, Alter JD, Browne HE, and Davis J: Family nurse practitioners in Eastern Kentucky. Med Care 9:160-168, 1971. 3. Rural Health Bill, PL95-210. 4. Sultz, HA, Zielenzy M, and Kinyon L: Longitudinal Study of Nurse Practitioners-Phase 1. US DHEW, PHS, HRA, #(HRA)76-43, March, 1976. 5. American Medical Association. Socioeconomic Issues of Health, Chicago, AMA, 1973. Howard University Center for Sickle Cell Disease Postgraduate Conference Announcement November 27-28, 1978 "Sickle Cell Hemoglobinopathies: Opposing Views and Controversies in Treatment" This conference seeks to focus on therapies where specific opposing views exist in an effort to evaluate the scientific or physiological merits for existing methods of patient care. In areas where the necessary scientific evaluation is available, the conference will seek to advance the standardizations of methods of care. Where supporting research data are not available the conference will seek to stimulate controlled clinical trials so that controversial approaches can be placed on a more rational basis. The conference has been designed to appeal primarily to physicians, nurses, allied health workers and clinical investigators. Credit for continuing medical education approval has been requested. The conference, sponsored by the Howard University Center for Sickle Cell Disease, will be held at the Hyatt Regency Hotel, 400 New Jersey Avenue, NW, Washington, DC 20001. For additional information direct inquiries to: Roland B. Scott, MD, Director, Center for Sickle Cell Disease, Howard University, 2121 Georgia Avenue, NW, Washington, DC 20059. 976 AJPH October, 1978, Vol. 68, No. 10