Across the United States, significant gaps remain in the rural health care workforce (Skillman et al., 2015; U.S. Department of Health and Human Services, 2013) with a deficiency of primary care providers an increasing concern (Goodfellow et al., 2016). Nurse practitioners (NPs) have been identified as well-suited for filling these gaps (Institute of Medicine [IOM], 2010; Rural Health Information Hub, 2018), yet NP graduates may need additional training to be fully prepared for positions in rural health care. Evidence indicates that health care providers are more likely to work in rural areas if trained in rural health needs and provided a rural clinical rotation (Skillman, 2015). This suggests that NP graduates who receive rural-focused training will be better prepared to provide primary care needs to rural communities (IOM, 2010; Kippenbrock et al., 2017). An initial first step in reducing rural health disparities is to develop effective and sustainable approaches for preparing NP students for professional practice. This article discusses a workforce development project for NP students interested in pursuing careers in rural primary care and the development of a rural-specific curriculum framework and subsequent training course.
Preparing NP students for rural primary care roles not only requires appropriate clinical knowledge and skills, but also accomplished communication, leadership, and critical thinking skills, coupled with self-directedness and confidence in their own abilities. Development of leadership skills for managing patient needs and working with clinical teams are key to readiness for practice as professional NPs (Joseph & Huber, 2015). Yet, moving from the role of a student to an autonomous professional can be daunting and experienced as feelings of being ill-prepared to meet job responsibilities and professional expectations as rural primary care providers (Sargent & Olmedo, 2013). Creating NP graduates ready to practice in rural primary care requires information and knowledge in rural culture and health care, in addition to mentoring by experienced NPs in rural clinical rotations.
In a study by Owens (2018), newly graduated NPs working in rural primary care assessed their perceived preparation and opinions related to successfully transitioning into skilled rural primary care providers. Three primary concerns were identified: learning about and experiencing first-hand rural health care; interactions with both patients and nursing staff for building positive self-perception; and 3) opportunities to practice autonomously, negotiate challenges, and to interact with a diverse panel of patients (Owens, 2018). The findings in this study are consistent with the concepts of transitioning as described by Chick and Meleis (1986) as a process and an outcome, and summons nurse educators to close the gaps in NP preparation through the provision of specific curricular content focusing on rural primary health care.
Building on these concepts, a rural-specific curricular framework of didactic content coupled with clinical practicum in rural primary care was developed to prepare NP students for roles as rural health care providers. Building on the work of Owens (2018) concerning rural health care and NP rural practicum experiences, a review of literature focused on clinical placement of NP students in rural communities was foundational in developing this innovative rural curricular framework and course content.
The curriculum framework has two main goals: to facilitate readiness to practice in rural primary care through didactic content focused on rural culture to facilitate the desire, intent, and skills needed by graduate NPs to practice in rural primary care; enhance NP students' perceptions of their abilities to practice in rural communities to help them consider their own perceptions and attitudes regarding rural health, patient needs, cultural humility, communication barriers, practicing autonomously, and applying evidence-based research in their decision making. Specific course content provided additional educational training beyond the basic NP core curriculum through six specific core topics:
Rural culture on specific values and beliefs of rural residents to facilitate effective communication
Health literacy skills using evidence-based methods to assist students with clear and concisely communicated care plans
Patient advocacy for building a network of partners with other health care providers, community leaders, and family members to meet patients' needs
Interpersonal communication skills to build trust with patients
Patient management using advanced procedural technical skills to build confidence and a simulation activity with standardized patients using case scenarios typical in rural primary care
Resilience and self-care strategies to prevent burnout and building resilience to promote life-long careers in rural primary care.
An important factor in developing this framework was collaborating with a health care system partner with rural primary care clinics to facilitate student placement with qualified NP preceptors. To attract NP students to participate in this additional learning opportunity, students met their clinical course requirements, received a financial stipend, and had the opportunity for extra clinical skills preparation. The course content and 4-month practicum (one 16-week semester) in a rural primary care clinic allowed students ample opportunities to put into practice the lessons learned through the didactic content and technical skills boot camp. Course content delivery via a hybrid modality of online lectures prior to group discussions enhanced applicability and flexibility in learning, often confounded by conflicting clinical and class schedules. Despite advantages of the hybrid online delivery, live bimonthly face-to-face sessions were added to enhance student participation and create opportunities for students to ask specific questions, interact with faculty and one another, and discuss and creatively problem-solve strategies to challenges encountered during their clinical practicum. Ten NP students (5 students per each 16-week semester) were selected to participate based on their successful performance in their advanced clinical program (during one of their last two semesters) and intentions to provide rural primary care following graduation. Financial stipends were awarded to NP students that could be used for tuition and to offset costs associated with their rural practicum. The selection of NP preceptors was based on their level of experience in rural health care.
Student evaluation occurred through pre- and postcourse surveys, student online journaling during the clinical practicum, formative assessment using online self-guided testing during the 16-week course, and summative assessment during a standardized patient simulation activity. A focus group session with participating students provided evaluation data at the conclusion of the 16 weeks. Directed content analysis categorized key concepts from the student journals and transcripts of the student focus groups. The project evaluator conducted the initial round of review and potential coding of key themes. Through group discussion with the project evaluator, the project faculty reviewed the initial coding to further verify, organize, and categorize the collected data into six distinct themes and to gain consensus on project findings.
Analysis of the student journals and postcourse focus group sessions revealed six themes correlating with the course content. Students indicated that they gained competence in rural culture and care delivery, increased their skills in health literacy and patient advocacy, and improved communication and negotiating ethical issues with patients and other providers. Students also reported enhanced skills in assessment and management of simple and complex health issues, and increased expertise in their technical skills such as suturing and diagnostic imaging. Additionally, students expressed awareness of the challenges of practicing in rural health care and the importance of resilience in preventing burnout.
Theme 1: Increased Appreciation and Understanding of Rural Culture
- I learned a lot about different cultural backgrounds. It made me change the way I care. It helped me open my mind about how to treat each patient individually.
- Learning to gain buy-in from patients…things that mattered to them—their way of life, farming, cattle, weather, kids.
Theme 2: Health Literacy
- Health literacy must be assessed on each patient. I cannot assume that a patient has a high health literacy without first assessing their reading comprehension.
- Antibiotic stewardship and bacterial resistance knowledge is low in many areas. These can be difficult concepts to explain and must be done at a level understandable to the patient.
Theme 3: Patient Advocacy
- In the clinic, when I come across patients with multiple morbidities, I feel it challenging to help and guide them in different aspects to maintain their health and quality of life. In these situations, I feel like I have to apply my leadership skills to not only guide the patients but also motivate them and collaborate with other professionals in the health care team to provide the patients with best possible care to promote their well-being.
- I did have to take a step back and realize how financial situations can impact care. I think that I need to do a better job at tailoring treatments and follow ups around the patient's availability of resources.
Theme 4: Interpersonal Communication
- Listening to your patients…especially in rural areas…building that trust is important and that comes by making them feel heard and listened to.
- I've struggled with knowing how to respond to some coments made by patients and people in the office regarding the political state of our nation…to know how to respond in a respectful, gentle manner without furthering the political banter.
Theme 5: Patient Assessment and Technical Skills
- I felt confident taking a thorough health history, performing physical assessments and developing a list of differential diagnoses to discuss with my preceptor.
- This is a small but BIG learning experience. I learned the importance of positioning and light when looking at skin. I was looking at the bottom of a patient's foot and could not see the extent of an infection until I got on the ground to look at the foot. A small lesson, but one I hope to remember.
Theme 6: Resilience and Self-Care
- I feel as new graduates we are going to have many stressors about our self-worth and self-awareness. I will put the new knowledge gained toward my new professional role.
- Persistence. You would follow guidelines but it would get knocked back to you a lot. You have to go off script a little bit.
Changes in the framework occurred between the two semesters based on collected student data. Students requested that face-to-face discussion sessions be added to the online-only didactic content as this method did not allow for adequate discussion or interaction with project faculty and the other student participants. A bimonthly live, face-to-face session was instituted with each live session focusing on the previous week's didactic content. Another improvement—instituted at the request of student participants—was providing the clinical skills boot camp earlier in the semester. Although students had reported the value of the technical skills taught, students unanimously indicated that they wanted the boot camp to occur earlier in the semester so they could use these skills earlier in the practicum. The technical skills boot camp is now offered in the first weeks of course delivery (Table 1).
Changes to Course Content and Delivery
There was a noted change in student perceptions on the pre- and postsurveys on readiness to practice in rural primary care. In the presurveys, students noted minor to moderate deficits in their confidence concerning technical proficiency and communication skills with rural patients. Postsurveys revealed improved confidence as practitioners, most notably, changes in confidence in technical skills postcourse and greater awareness of how best to work with and communicate with rural patients. The student self-assessments using self-guided testing following each week of the course delivery and discussion sessions with faculty remained neutral with no notable lack in student understanding of the course content. This finding was not surprising given that students had opportunities each week to ask questions and post concerns through their journal entries. This finding also seems appropriate considering that all of the NP student participants were either in their final semester or final two semesters prior to graduation.
Efforts to expand the rural primary care workforce with more advanced practice NPs demand changes to current didactic nursing educational models, as well as rural clinical learning experiences (American Association of Colleges of Nursing, 2015; Leflore & Thomas, 2016). Acquisition of such knowledge is essential for building meaningful, patient-centered partnerships with patients, their families, the community, and clinical team members (Ulrich-Schad & Duncan, 2018). The development of the framework discussed in this article was an attempt to meet several challenges in educating NP students for readiness to practice in rural primary care. For NP graduates interested in serving rural patient populations, understanding the unique perspectives of rural patients and increased proficiency in technical skills is paramount to care delivery. The faculty planners designed the curricular framework to be an evolving structure informed by the NP student participants and their perceptions of increased confidence as rural health care providers. This resulting curricular framework was a first step in helping NP students for readiness to practice for professional roles in rural primary care (Table 2).
Readiness to Practice for Professional Roles in Rural Primary Care
The delivery of health care in rural communities is contingent upon enough health professionals to fill rural provider shortages and resolve rural health disparities. The provision of an immersion learning experience that includes targeted didactic content and simultaneous clinical practicum in rural primary care can help to enhance NP students' confidence, knowledge, and the technical abilities for providing optimal rural primary care. On the basis of findings from a focused rural health care immersion course, NP students can be prepared to fill the health care provider shortage in rural communities.
A 16-week didactic and rural clinical practicum hybrid immersion course was implemented to specifically address rural culture, interpersonal communication, and building trusting relationships with patients and families, team members, and community members. Postcourse focus groups and data from participating NP student journals during the practicum indicated students gained a greater understanding and appreciation for rural culture and providing health care for rural patients. NP students reported the rural immersion course allowed them to advocate and negotiate effective plans of care for rural patients. Additionally, NP student participants reported an increased interest in working in rural primary care.
- American Association of Colleges of Nursing. (2015). Re-envisioning the clinical education of advanced practice registered nurses. White Paper. https://www.pncb.org/sites/default/files/2017-03/APRN-Clinical-Education.pdf
- Chick, N. & Meleis, A. I. (1986). Transitions: A nursing concern. http://repository.upenn.edu/nrs/9
- Goodfellow, A., Ulloa, J. G., Dowling, P. T., Talamantes, E., Chheda, S., Bone, C. & Moreno, G. (2016). Predictors of primary care physician practice location in underserved urban and rural areas in the United States: A systematic literature review. Academic Medicine, 91(9), 1313–1321 doi:10.1097/ACM.0000000000001203 [CrossRef] PMID:27119328
- Institute of Medicine. (2010). Redesigning continuing education in the health professions. National Academies Press.
- Joseph, M. L. & Huber, D. L. (2015). Clinical leadership development and education for nurses: Prospects and opportunities. Journal of Healthcare Leadership, 7, 55–64 doi:10.2147/JHL.S68071 [CrossRef] PMID:29355179
- Kippenbrock, T., Lo, W. J., Odell, E. & Buron, W. (2017). Nurse practitioner leadership in promoting access to rural primary care. Nursing Economic$, 35(3), 119–126.
- LeFlore, J. L. & Thomas, P. E. (2016). Educational changes to support advanced practice nursing education. Journal of Perinatal & Neonatal Nursing, 30(3), 187–190 doi:10.1097/JPN.0000000000000201 [CrossRef] PMID:27465446
- Owens, R. A. (2018). Transition experiences of new rural nurse practitioners. Journal for Nurse Practitioners, 14(8), 605–612 https://doi-org.proxy.library.umkc.edu/10.1016/j.nurpra.2018.05.009
- Rural Health Information Hub. (2018). Rural health workforce. https://www.ruralhealthinfo.org/topics/health-care-workforce
- Sargent, L. & Olmedo, M. (2013). Meeting the needs of new-graduate nurse practitioners: A model to support transition. Journal of Nursing Administration, 43(11), 603–610 doi:10.1097/01.NNA.0000434506.77052.d2 [CrossRef] PMID:24153203
- Skillman, S. M., Hager, L. J. & Frogner, B. K. (2015). Incentives for nurse practitioners and registered nurses to work in rural and safety net settings. University of Washington Rapid Turnaround Brief.
- Ulrich-Schad, J. & Duncan, C. M. (2018). People and places left behind: Work, culture and politics in the rural United States. Journal of Peasant Studies, 45(1), 59–79 doi:10.1080/03066150.2017.1410702 [CrossRef]
- U.S. Department of Health and Human ServicesHealth Resources and Services AdministrationNational Center for Health Workforce Analysis. (2013). Projecting the supply and demand for primary care practitioners through 2020. https://bhw.hrsa.gov/sites/default/files/bhw/nchwa/projectingprimarycare.pdf.
Changes to Course Content and Delivery
|Initial Curriculum Content||Adjusted Curriculum Content|
|Hybrid online student discussions||Live face-to-face student discussions|
|Technical skills boot camp mid-semester||Technical skills boot camp early semester|
Readiness to Practice for Professional Roles in Rural Primary Care
|Facilitating Readiness to Practice||Change in Student Perception of Readiness|
|Curricular content: rural health culture, literacy and community advocacy, communication and leadership, resilience, self-care, and ethics in nursing||Perceptions of rural health and patient needs, cultural humility, managing communication barriers, practicing leadership, and acquisition of confidence for building meaningful relationships and evidence-based decisions|
|Skills boot camp to enhance technical skills proficiency||Complex clinical skills, confidence for serving patient needs|
|Live face-to-face sessions with students||Improved communication, leadership, and relationship building through teamwork|
|Live face-to-face simulation using rural health case studies||Confidence to accurately diagnose, create a care plan, and engage with patients|