Ryan, Hmson, Hodnirkiand Donoh 7

Education for Rural Health Professionuls

Education of Health Care Providers for the Rural Setting: A Family Nurse Practitioner Demonstration Program* Rebecca Ryan, Charlene M. Hanson, Donna Hodnicki and Margaret Wyss Dotrob

ABSTRACT: Spurred by mass concern over shortages of hedth care pro- viders, the country i educationalsystem has, over the past ten years, produced an ample supply (in some areas a near glut) of health care professionals. Studies demonstrate, however, that these professionals tend to cluster in the affluent metropolitan and suburban areas. Residents of rural areas are still signzficantLy underserved. In the heavily rural southern half o f Georgia, this problem has reached a critical peak. Georgia Southern College (GSC) is a rural basedcollege locatedin the heart of rural south Georgia. In order to ad- dress some of the health care problems of its constituency, GSC, with federal support, established a Nursing Department and a Family Nurse Practitioner program with a commitment to recruit nursing students from the rural area, educate them in rural settings, and provide appropriate preparation f i r the unique experience of working in the rural environment. The program has been very successful in producing highly skilledgraduates who do stay and work in the rural areas, providing health care at reasonable costs. This paper descn'bes the setting (ruralsouth Georgia), the need, the program implemen- tation, and the impact (numbers of graduates actually working in rural set- tings, and innovative projects initiated by graduates).

Unequal access to medical and nursing care is one of the most difficult problems confronting the health care delivery system of the United States. Physicians, professional nurses, nurse practitioners, physician's assistants, hospitals, specialty practices, and clinics tend to cluster in affluent suburban areas. Rural residents (approximately 28% of the nation's population in 1980) have seldom benefited from the sophisticated health care technology enjoyed by others, although comparisons of urban and rural mortality and morbidity data indicate that rural residents often have greater need (Schmidt, 1979).

The Nature of Health Care Provider Shortages A shortage of health care providers tends to be a self-perpetuating

problem. A community that has inadequate numbers of health care profes-

'The Family Nurse Practitioner Program at Georgia Southern College has been funded by a grant from the Nulsing Division of the U.S. Public Health Service. Additional information and details about the program can be obtained by writing the authors at the Department of Nursing, Georgia Southern College, Landrum Box 8158, Statesboro, Georgia 30460-8158. THE JOURNAL OF RURAL HEALTH

VOLUME 2. NUMBER 1 JANUARY 1986

8 The JoumdofRurd Health

sionals often finds it difficult to recruit and retain doctors and nurses. Many health care professionals do not want to work in areas lacking in facilities and in collegial relationships and support services provided by other types of health care providers. Most physicians want to work in an area with an ade- quate number of nurses and vice versa (Cordes and Wright, 1985).

The experience of recent years have shown, however, that merely pro- ducing more health care professionals is not the solution to the maldistribu- tion problem. Between 1960 and 1979 the number of active physicians in the United States increased by almost 40 percent. However, during that same period of time the number of physicians practicing in rural areas ac- tually declined (Schmidt, 1979). Most allied health education programs are in urban centers and their students become accustomed to the urban life- style and adopt the values of the large urban medical complex. Such educa- tional programs are based on the metropolitan health care model of a high volume, and technological complexity with a variety of sophisticated equip- ment, facilities, literature, support staff, and specialists (Cordes and Wright, 1985). The student educated in such a setting is likely to come to associate quality of care with the presence of these elements. Research studies have indicated that doctors and nurses trained in urban centers wish to live and establish their careers in those same types of areas (Margrum and Tigges, 1982). Another study (Cooper, et al., 1975) found that the areas where practitioners and their spouses were raised was a major factor in their choice of clinical setting, along with opportunities for academic and profes- sional associations.

Intervention Strategies Furthermore, although programs such as the National Health Service

Corps and other loan programs which require graduates to “work off” a portion of their indebtedness by practicing in an underserved area have made some impact, this is an inadequate solution to a massive problem. Schmidt (1979) concluded:

In general, loan programs forgiving repayment in return for service in rural areas have not been effective, with most students electing to pay back the loans rather than serve in a shortage area (p.44).

Additionally, many of the urban graduates who do work for a period in rural areas, experience so much culture shock that when they have fulfilled their obligations they choose to return to more familiar surroundings (Cordes and Wright, 1985).

Providing Nursing Care in the Rural Setting Even those who do practice in the rural area may be inadequately

prepared for the task of providing health care in a setting with unique cultural and sociological dimensions and with complex practice demands.

Ryan, Hanson, Hodnicki andDonoh 9

Lassiter (1985) described rural nursing in terms of the complex demands of working in an medically isolated environment:

Rural nursing differs from urban nursing in the diversity of knowledge needed. The rural nurse is frequently a lone health practitioner, refer- ral and consultation resources are not readily available. Rural clients are highly influenced by traditional community and family values and communities are often geographically isolated (p. 2 4 ) .

There is a considerable base of literature endorsing the concept of en- rolling students from rural areas in the hopes that they will return to work in the rural area (Cooper, et al., 1975; Schmidt, 1979). Some of the most suc- cessful efforts in the direction of increasing the numbers of practitioners at- tracted to and retained in the rural areas have involved decentralization of education programs - to expose students to rural practice and to involve rural practitioners in the educational process.

A major factor in the solution to the problem of inadequate numbers of providers and of inadequate preparation for the setting, we contend, lies in locating educational facilities and clinical practice settings in underserved rural areas, recruiting students with ties to those areas, and offering educa- tional programs that are tailored to the special needs of health care profes- sionals in rural areas. This is the approach adopted by the Family Nurse Practitioner (FNP) Program at Georgia Southern College’s Department of Nursing. In the sections which follow, we describe the South Georgia situa- tion, the rural based Family Nurse Practitioner Program and the program’s success.

Inadequately staffed health care delivery systems in rural areas have a very negative impact on the health status of rural residents. The problem is increasing because the population of rural areas, nationally and in most areas of the country, is the fastest growing population group and because the overall rural population growth is seldom matched by increases in the number of health care providers. The shortage of health care professionals is a problem of critical proportions in rural south Georgia. In land area, Georgia is the largest state east of the Mississippi River, and the area defined in this paper as south Georgia encompasses an 81 county area south of a line that begins at Harris County on the West and extends to Burke County on the East, The land mass of this area is more than half of Georgia’s total area of approximately 58,000 square miles. Seventy of the counties in this area are currently defined (by the U.S. Department of Commerce, Bureau of the Census) as nonmetropolitan and only eleven are defined as metropolitan. The population of this area is more than one million, six hundred thousand people (approximately 30% of Georgia’s total population). This is the target area of Georgia Southern College’s Family Nurse Practitioner Pro- gram - a program developed especially to meet the pressing needs for primary health care services in rural south Georgia.

Tab

le 1

: So

cio-

Eco

nom

ic D

ata

Rel

ated

to H

ealth

Sta

tus i

n M

etro

polit

an an

d N

on-M

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reas

in

the

Uni

ted

Stat

es a

nd in

Nor

th a

nd S

outh

Geo

rgia

UN

ITED

STATES

GEO

RG

IA

NO

RTH

GEO

RGIA

SOUTH

GEO

RGIA

Tota

l M

etro

N

on-M

eao

Tota

l M

etro

N

on-M

etm

Total

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N

on-M

em

Tota

l M

etm

Non

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m

POPU

LATI

ON

Whi

te P

opul

atio

n %

OF

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LATI

ON

AFD

C R

ecip

ient

s %

OF

POPU

LATI

ON

Wor

kers

ove

r age

15

% O

F PO

PULA

TIO

N

Med

ian

Yrs

. Edu

catio

n

Per C

apita

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me

SQU

AR

E M

ILES

PE

R 10

0,00

0 PE

OPL

E

226,

545.

805

189,

035,

012

83.4

10,3

40.7

46

4.6

96,6

72,2

03

42.7

11.9

1

s 9,4

97

3.53

7.01

0 15

61

163,

084,

I86

62,7

88,6

00

133,

116,

318

55.4

31,1

97

81.6

88

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7.59

4.85

9 2,

314,

751

4.9

3.7

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63,6

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24,6

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44.0

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7 I1

60

$ 10

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7.61

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494,

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2.47

5.71

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3 39

43

5,46

3,10

5

3,94

9,58

3 72

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218.

679

4.0

2,35

6.12

0 43

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11.3

7

s 8.0

41

58.0

85

1063

3,14

6.00

0

2,25

6,21

4 71

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119,

913

3.8

1.42

3.1

18

45.2

11.9

0

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127

9,63

9 30

6

2,31

7,10

5

1,69

3,36

9 73

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4.3

933,

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40.3

10.6

4

$ 6.

567

48,4

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209 I

3,46

4,52

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2,65

8,74

1 76

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110.

431

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1,71

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81.6

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819

41.9

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2

$7.0

02

15.5

47

1404

1,99

8.57

9 78

8.76

4

1,29

0,84

2 10

0.62

7 64

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63.5

108,

244

41.7

80

5.4

5.3

799,

944

330,

761

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41

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2 11

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$ 7,

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2

DA

TA S

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Ryan, Hmson, H o d n d i a n d Dorroh 11

Health Status of Rural South Georgia Residents The need for primary health care providers in rural south Georgia could

hardly be overstated. Although 40% of all Georgians live in rural areas (Note l) , in south Georgia this figure is much greater (72%). A number of factors interrelate in south Georgia to produce a significantly depressed health status area. A review of the rural health literature identifies age, in- come, and education as the major correlates of an area’s health status. In his report for the Subcommittee on Rural Development, Schmidt (1977) stated that “poor people and old people have more health problems . . . Both poorer and older rural need more health services . . . There is also a correla- tion between education and health” (p. 40). The data in Table 1 indicate that the residents of south Georgia - especially the rural counties - have less education and lower incomes than the rest of Georgia (which is below the nation as a whole). There are also high percentages of non-whites in south Georgia. Health care literature demonstrates that these non-white groups have greater health care needs (Schmidt, 1979).

Mortality Rates. Differences in mortality rates serve as indicators of both the overall health status of an area and the need for health care pro- viders (Schmidt, 1977). Within south Georgia, there are significant dif- ferences in mortality rates between the urban counties and the rural coun- ties, as illustrated in Table 2, page 12.

The rural rates remain higher across all of the major cause of death categories. The greatest differences are in the number of deaths related to stroke and heart disease. The stroke related death rate for the rural counties is 50% higher than the rate for the urban counties and the death rate for heart disease is 42.9% higher. Obviously, people can, and do, go into urban areas for diagnosis and critical medical treatment which they cannot obtain in the rural area. However, because the distances are very great and the costs are high, the sometimes life-saving prevention and early intervention aspects of care may be neglected in the absence of reasonably priced health care in the local area. In land mass, Georgia is one of the nation’s largest states, yet, there are only four federally designated urban areas in the southern half of the state. The distance to an urban medical center can easily be a hundred miles.

Infant Mortality. Infant mortality is a major problem throughout Georgia (see Table 2). Although special efforts by public health officials to improve prenatal, intrapartum, and postnatal services to women and infants have effected a significant improvement in the rates (Zaro, et al., 1984), they are still high by comparison to national norms. Even with the improve- ment, in 1982 Georgia ranked 39th among the states in terms of infant mor- tality. Babies are dying at the rate of four per day in Georgia - and too many of these succumb to preventable illnesses (Council on Maternal and Infant Health Care, 1784).

Georgia’s mothers tend to be younger than the national norm. In 1982, nineteen percent of Georgia’s births were to teenage mothers. Additionally,

Tab

le 2

: D

emog

raph

ic D

ata

for M

etro

polit

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nd N

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polit

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reas

in th

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rgia

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l M

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te P

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OF

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PER

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OR

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ths

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TE

226,

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27

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594

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12.6

1,98

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163,

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186

133,

116,

318

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14 The JournalofRural Health

one-third of the babies were delivered to mothers who did not have a high school education (Council on Maternal and Infant Health, 1984). Adoles- cent mothers are more likely to be impoverished, and, therefore, less likely to receive adequate health care (Mednick et al., 1979). It is estimated that 7 % of the pregnant women in Georgia do not receive adequate prenatal care - 1,280 received no prenatal care at all in 1982 - and that the infant mor- tality rate is 500% higher among babies whose mothers did not receive at least four prenatal health visits during the pregnancy (Council for Maternal and Infant Health, 1984, p. 4). Whereas 8.5% of Georgia newborns had birth weights below 2500 grams, only 6.5% of newborns nationally had such low weights. The Council of Maternal and Infant Health (1984) stated that “Many poor pregnant women live in communities in which prenatal care and infant follow-up are not easily accessible . . . Infant mortality rates are highest in areas where prenatal care resources and accessibility are low” (p. 3). The Council offered the following Georgia statistics:

039 counties have no hospitals and 21 of the counties that have hospitals do not provide obstetric services;

-47 counties are without physicians providing obstetric services and 14 counties have physicians who accept obstetric clients but will not ac- cept Medicaid patients; 54 counties have physicians who provide obstetric services but do not accept medically indigent clients; and 17 county health departments do not provide prenatal care services.

Elderly Population. Rural south Georgia also has a high population of people over the age of 65 years. Individuals of that age tend to have multiple and chronic health problems (Schmidt, 1979; Sutherland, 1983). Of par- ticular note are the very high rates of hypertension and stroke in this area. The elderly particularly dislike to travel long distances to receive health care and they may lack means of transportation. Thus, important aspects of preventive care and early intervention may be missing in the absence of primary care services provided in, or near, their homes.

Availability of Health Care Services The socio-demographic data described above present a strong picture of

need for health care services. The data in Table 3 contrasts rural south Georgia with urban and rural data for Georgia and north Georgia and with national urban and rural data to illustrate the dramatic health care shortages of rural south Georgia.

The physician rate for rural south Georgia is 58% below the national rate and the rate of registered nurses is 40% below the national rate. To fur- ther complicate the situation, providers tend to be less well prepared. Nurses, as the largest group in the health care network, provide a strong

case in point. ’ ’ Nationally, 29.2 O h of registered nurses have baccalaureate “

Ryun, Hanson, Hodniciki and Dorroh 1I

or higher educational preparation, but in Georgia only 20.2% of R.N.’s are qualified at a baccalaureate or higher level (Board of Regents, State of Georgia, 1983). The rate for south Georgia and rural south Georgia is known to be considerably below Georgia’s state level but appropriate com- parative year data are not available.

The Nurse Practitioner Movement The nurse practitioner movement has a great deal of potential for

enhancing rural health care in Georgia. The number of nurse practitioners is increasing rapidly throughout urban and rural Georgia. A 1983 survey of Georgia nurse practitioners (Tatro, Krause and Hanson, 1983) reported that there were 340-360 nurse practitioners working in Georgia. The data further indicated that:

090% of Georgia’s nurse practitioners were board certified;

nurse practitioners in Georgia tended to earn $19,000-$24,000;

32 % were working in rural areas; and

044% worked in health departments and another 27% in other primary care settings.

A Demonstration Project

For these reasons, Georgia Southern College, a rural college with a strong commitment to special preparation of health care providers for the rural community, in cooperation with Georgia’s Department of Health and Human Resources developed a family nurse practitioner program. The pro- gram has been funded by the Nursing Division of the Public Health Service, since 1982. Student tuition is only $140.00 for the entire program. The pro- gram is a continuing education program with eight months of intensive didactic and supervised clinical work and an additional four months of supervised clinical work with a preceptor. The program also offers a pilot program under which an R.N. who is qualified for admission to the FNP program and the Department of Nursing may receive thirty-three hours of junior level credit toward a B.S. in Nursing.

Aside from providing a well-qualified family nurse practitioner for the underserved rural area, the major thrust of the program is to prepare the stu- dent to be an effective practitioner in the rural environment. There are some major differences in the background and work requirements of urban and rural health care professionals. A 1981 study comparing nurses in rural and urban Georgia settings demonstrated that there are many significant dif- ferences in their tasks and their level of preparation (Isler, 1983). Rural nurses (as a group) were older, had been in their jobs longer, practiced in general care (as opposed to specialty areas), and had less academic prepara-

16 The Journal of Rural Health

tion (in this sample, only 9% of R.N.s in rural hospitals had a B.S.N. as their employment entry level as opposed to 21% of the R.N.s in the urban hospitals).

In a comparison of urban and rural nursing settings Lassiter (1985) has noted that:

Urban nursing does not require of one person such diverse functions as emergency care, management of a primary health care center, com- munity health assessment, leading health promotion groups, and health care with migrant workers. Diversity of functions and applica- tion within a rural context make rural nursing distinctive (p. 2 4 ) .

Unfortunately, however, as the data above indicate, rural R.N.s in Georgia are, academically speaking, less well prepared for the complicated tasks and for the decision-making involved.

The goal of Georgia Southern College’s family nurse practitioner pro- gram is to produce graduates who promote the health status of residents of the rural southeast by functioning safely and effectively in the role of a primary health care provider in the unique rural setting. This function of the family nurse practitioner (urban or rural) should include:

@Health promotion: promoting a state of optimal well-being in the community through community education, consciousness raising and professional development for the nursing community.

Illness prevention: preventing illness and disability on an individual basis and on a community basis through health counseling, screening, risk factor analysis, and immunization programs.

Care during illness: caring for clients in the various settings preferred by rural residents during episodic and chronic illnesses.

@Counseling and client education: promoting health and well-being by helping clients understand the factors influencing their health status, and supporting clients in stressful situations.

Referral: supporting the client with information on community resources appropriate to their needs; assisting the client (when neces- sary) in seeking further careIhelp; and following-up to determine if appropriate assistance was obtained and needs met.

These categories overlap significantly and are somewhat cyclical. To realize this is to become more aware of the full function of the family nurse practi- tioner. For maximum efficiency the family nurse practitioner must have a continuing relationship with the family which, at various points in time, reflects most or all of the functions listed above. Such a relationship enhances the FNP’s ability to provide care in a context appropriate to the client’s age, race, sex, cultural background, socio-economic status, physical

Ryan, Hanson, Hodnickt andDorroh 17

and emotional history; to assure the client access to the health care delivery system; and, to ensure the continuity of care.

The family nurse practitioner working in a rural setting must have a broad knowledge base. Cummings (1978) has asserted that the rural setting - with its absence of specialists and specialized technicians - requires knowledge of a very broad range of areas. The knowledge of a competent (and experienced) nurse must be supplemented with data from many fields including:

Medicine: Knowledge about the normal functioning of all the physical systems, as well as disease states, symptomatology, and usual therapies is necessary for the FNP (especially in the rural setting where sophisticated diagnostic technology and access to specialty care pro- viders - nutritionists, physical therapists, psychiatrists, and physician specialists - is very limited).

.Pharmacology: The FNP must be familiar with all of the commonly used drugs - their actions, their indications, contra-indications, and side-effects.

Psychology: The FNP must be able to assess the basic psychological status of the client/family, interpret the impact of health functioning on psychological status (and vice versa), and assist the client /family in coping with health problems or other life stressors which are having a negative impact on health and well-being. Knowledge of basic psychological concepts, family dynamics, parenting, and counseling approaches is a must.

Sociology: It is critical that the FNP working in a rural setting be able to interact with the client within the context of the client’s cultural background. A basic knowledge of the sociological correlates impact- ing health and health practices in the rural southern community - race, religion, ethnic background, social and economic status, belief structures, folk medicine, and physical and psychological isolation, - is necessary. Other important topics include the sociology of aging, rural sociology, and cultural anthropology.

Skills In the clinical setting, the family nurse practitioner must be able to in-

teract effectively with clients and colleagues; use their senses to obtain infor- mation through palpation, auscultation, and percussion; record findings in an organized, complete, and legible manner; analyze data and make good decisions; act to implement decisions made; and evaluate and provide follow-up for the care given. In the community setting the family nurse practitioner should be able to interact and cooperate with other professionals

18 The JournalofRural Health

to develop, enhance, and utilize programs which impact directly or indirect- ly on the health and well-being of rural residents. These basic skills must be reflected in the ability to:

*conduct a complete, effective, and efficient health assessment including a medical history, a physical examination, a full documen- tation of findings, a differential diagnosis, appropriate laboratory tests, and a final diagnosis;

*develop, implement, and evaluate a case management plan;

*make an appropriate referral (when indicated) and follow-up with the client to epsure continuity of care, to ensure that the client under- stands the therapy, to support compliance with the therapeutic regi- men, and to support the client’s involvement in the planning of his or her own health care;

*educate and counsel clients, families, and (whenever possible) whole communities to promote health and well-being and prevent illness and disability; and

*consult with other health care providers and social service agencies to provide and coordinate services to individuals and families and to develop programs which enhance the health status of the community.

The program currently utilizes a fully modular curriculum with objec- tives, materials, and evaluation procedures fully specified for each learning activity (Note 2) . The didactic phase of the year-long program is contained in the first eight months. The program is completed with a 16 week precep- torship. The goal of the preceptorship is to give the student an opportunity to develop and refine clinical skills under the careful supervision of a precep- tor in conjunction with the Faculty of the Program. This is also the period during which the Faculty completes evaluations of the students to ensure that they are fully competent. The students are expected to choose a precep- tor who will give them the variety of experiences they need. This includes pediatrics; obstetrics; gerontology; chronic disease, acute, and episodic ill- ness. Several of the students have had more than one preceptor in order to fulfill these requirements. The preceptor may be a primary care physician, a master’s-prepared nurse practitioner, or a masters-prepared clinical nurse specialist. The ideal preceptor is a family nurse practitioner working in a primary care setting. Students are practicing with Family Practice MDs, OB/GYN MDs, in psychiatric hospitals, public health departments, and private practices.

R y m , HdnJon, Hodntckt andDorroh 19

Recruitment of Students and Selection Criteria The greatest priority in the recruitment and selection of students is

given to candidates who will be able to work successfully as family nurse practitioners in medically underserved rural areas (as indicated by work history; letters of reference; quality and quantity of academic background; commitment and demonstrable ties to the rural community). The most re- cent class represents a broad geographic area in the rural southeast and has considerable diversity in terms of professional and personal backgrounds as described below:

*aged 24 to 52 years (70% between 30 and 45);

090% female;

88 % rural or small town background;

064 % have lived in Georgia for 10 years or more; and

.all registered nurses (39% AD, 31% Diploma, 14% BSN) with two years experience.

Program Evaluation Data about the students are collected upon their entry into the program

and twelve months after their graduation. Data have now been collected for four classes (all four classes - 44 students - have been surveyed at the point of entry and three classes - 28 students - have been followed-up). New students complete a Student Characteristics Form on their first day of classes. A questionnaire asking for information about their current activities is mailed to each graduate twelve months after graduation. Several follow- up phone calls are made to non-respondents requesting that they submit in- formation. (Response rates for the Student Characteristics Form have been 100%; whereas, response rates for the Follow-Up Evaluation have been 86.4 YO .) The findings indicate that:

all graduates have passed the American Nurses Association’s FNP Certification Examination;

93.2 % were still in Georgia;

090.0% were working full-time;

52.4% were working in public health departments; and

82.6% had jobs that were specifically for nurse practitioners.

20 The Journai of Rurd Health

One of the major objectives of the program is to provide high quality cost- effective care. The survey results are indicative of success. Supervisors surveyed were overwhelmingly in agreement that program graduates provid- ed quality services (Note 3). Most of the graduates are paid straight salary. Salaries generally ranged from $19,000 to $24,000 (Note 4). Approximately one-third of the program graduates (35%) work in settings where clients have the option of a sliding scale and most (53%) see Medicare-Medicaid clients. The majority (59%) see 11-30 clients per day. Where specific fees are charged for visits to the NP:

57% see clients who pay $20.00 or less for a first visit; and

*87% see clients who pay $20.00 or less for follow-up visits.

The data presented in Table 4 indicate that 79% of the program graduates have remained in rural areas and are working as family nurse practitioners providing care to the underserved residents of the rural Southeast. Three of the other six graduates are working in urban areas designated as medically underserved. Only 11% of the graduates have sought practice settings in more urban areas. The class of 1984-85 has just graduated. More than eighty percent of these students already have commitments to work as family nurse practitioners in underserved rural areas.

The range of activities of program graduates is very broad and in- novative. One graduate helped to develop, now coordinates, and pruvides clinical care in the first grant-funded migrant health,care project in the area. Another graduate is developing an industrial health promotion model for a small rural industrial plant. A third collaborates as part of an inter- disciplinary team in a pain clinic serving urban and rural residents with in- tractable pain. Others manage hypertensive programs, work in rural mental hospitals, and work in private practices in the rural area.

Table 4: Work Status of Program Graduates by Class

Number of Number Currently Number Working in

Graduates Working as NPs Underserved Rural Areas

Class of 1982 6 6

Class of 1983 8 6

Class of 1984 14 14

6

s

11

Totals 28 26 22

Ryan, Hanson, Hodnzcki andDorroh 21

Conclusion The health care status of residents of the rural southern half of Georgia

(an area consisting of 81 counties and a population of 1,209,815 people), was described above. The area has a high risk population profile combined with an inadequately staffed health care network. The total mortality rate was 9.6% above the U.S. rate and the infant mortality rate was 24.6% above the national rate.

The inadequate distribution of health care providers in the United States is a major problem in areas such as rural south Georgia. Programs which provide for educational loan cancellations for health care providers who work in the rural area have not been successful in improving the situa- tion. This paper presents the model of recruiting nurses from the rural area, and educating them in the rural area, as a sort of “grow your own health care network” model.

The experience of this project demonstrates that a high quality program can be established in the rural area and can produce graduates who will stay in the rural area and provide care to the underserved populations at minimal cost. Such a program must be comprehensive in it’s coverage of the broad range of issues likely to be faced by a practitioner working in an isolated set- ting and must prepare the graduate for the cultural environment of the rural area.

NOTES

1. For the purposes of this article the terms urban and rural are used relatively interchangably with the terms metropolitan and nonmetropolitan. For the purpose of data analysis and tab- ulation the “Human Resource Profile County Codes” developed by the Office of Manage- ment and Budget (OMB) are used. These county codings were last revised in 1978. Other, more current, coding scales have been released for the state of Georgia but could not be used in these analyses because they were not nationally consistent. County definitions based on the different scaling techniques were compared and differences were found to be very minor.

2. Copies of curricular material will be provided upon request. Address all requests to the Fam- ily Nurse Practitioner Program, Georgia Southern College, Landrum Box 8 158, Statesboro, GA., 30460-8158. Please enclose a check for ten dollars to cover the costs of photocopies, postage, and handling.

3. Supervisors were surveyed by mail at the time of the twelve month follow-up evaluation, the response rate was 45 % .

4. Data on salary are not available from the six students in the first class. These analyses are based only on the twenty-two students of the 2nd and 3rd classes.

REmRENCES

Board of Regents “The Eighties and Beyond: A Commitment to Excellence, Assessment, Resource Book.” Atlanta, Georgia: University of Georgia, 1983.

Cooper, J. et. al. “Rural and Urban Practice: Factors Influencing the Location Decision of Primary Care Physicians,”Inquiiy, 1975, 12 , 18-24.

Cordes, S. and Wright, J. “Rural Health Care: Concerns for the Present and Future.’’ In Review of Allied Health Education, Vol. 5. University of Kentucky Press, Forthcoming 1985.

Council on Maternal and Infant Health Care, “Legislative Priorities, ” GoodBeginnzngs, 1984, 3(2), 1-6.

22 The JournalofRural Health

Cummings, D. "What aRural FNP Needs to know." Amencan JournalofNurszg, 1978. Isler, B. "Urban and Rural Georgia Hospital Study," Unpublished manuscript, 1983. Lassiter, P. "Education for Rural Health Professionals: Nurses," JournalofRural Health, 1985.

l (1) . 23-26. Margrum. W.M. and Tigges, K.N. "A Transdisciplinary Mobile Intervention Program for

Rural Areas (Developmental Disabilities. Pediatrics, Rural Health). The Amencan Journal of Occupational Therapy, Val. 36, No. 2 .

Mednick. B.R., Baker, R.L. and Sutton-Smith. B. "Teenage pregnancy and peririatal mortali- ty." Journal of Youth and Adolescence, 1970,63 ~ 795 -797.

Schmidt, H. , "Health of and Health Services to Rural People," RuralDevelopment: An Over- view, Washington, U.S. Government Printing Office, 1979,31.

Sutherland. D. "Rural Elderly Confronted by Special Circumstances," Perspectzve on Agivg, May/June 1983.

Tatro, E., Krause. K. and Hanson, C., Nurse Pructztzoners in Georgia. Georgia Nurses Associa- tion. Nurse Practitioner Conference Group, Unpublished data, 1984.

The Journal of RURALHmmH

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Correspondence is welcomed on all issues and con- cerns relevant to rural health Please keep your text to about 500 words