Improving Rural Health Outcomes: the innovative rural

nurse education initiative

JoAnn Klaassen, RN, MN, JD

Clinical Assistant Professor

Director, UMKC Rural Nurse Initiative

©Not for use without permission

Focus on rural health

• Rural health outcomes are universally worse than urban health outcomes– Higher MVA rate/MVA deaths– Higher smoking & substance abuse rates– Significantly higher male suicide rates

(Harkness & DeMarco, 2012; Rural Assistance Center, 2011)

– Higher mortality rate for ages 1-24 (Bennett et al., 2008)

– Less access to preventative/perinatal care– Higher rates of occupational injuries (Bushy, 2007)

– Higher levels of non-insured, under-insured individuals

Focus on rural health

• Fewer resources available i.e. HPSA• Disproportionately Medicare/Medicaid funded• Community-based focus• Targeted for major changes via PPACA• Technology – tele-health in particular – seen as

an emerging solution• Future funding and resource allocation are a

concern• Regulatory burdens are disproportionate

Rural Hospitals

• Tremendous variability• Significant underfunding from Medicare (as

compared to urban)• 470 hospital closures over past 25 yrs.• Some revitalization via CAH, block grants, etc.• Initially left out of health care law• Fewer physicians and specialists, shortage of

nurses• Significant locus of control shift from

community to federal/state govt

Rural hospitals

• Increasing pressure on rural hospitals struggling to comply with meaningful use, quality indicators and

• Avalanche of new regulations• Potential negative impacts of ACOs• Under health care reform the potential

for community-oriented care to be subsumed by large corporations

Implications• Rural communities need visionary and

innovative health care personnel• Every health care provider will need to operate

at the “full extent of their scope of practice” (Wakefield, 2011)

• Community collaboration is critical• Emphasis on aggregate and preventive care• Current information and appropriate

educational levels/skill development are essential

Rural nurse role

• Perform as expert generalists• Function within the community culture• Rely on both formal and informal networks for

health care services• Apply ethical principles in a cultural context

(Bushy, 2009)

• Independence, creativity, innovation required• Flat career ladder requires flexibility to

incorporate non-traditional roles

Rural nurses• More rural nurses with associate degrees which does not

provide– Leadership skills, community/preventive health, mental health,

policy development, etc.• Fewer opportunities to advance education i.e.

– Travel to attend continuing education courses/conferences is a significant challenge (Mason, Leavitt & Chaffee, 2012)

• Less exposure to emerging technologies but higher need• Rural nurses’ average age slightly higher than urban

nurses → older learners, higher learning curve• Often wear multiple hats in the health care setting – some

for which they are not educationally prepared• Expectation for more complexity in role (Wakefield, 2011)

Nursing Education• Majority of baccalaureate nursing

programs are located in urban areas

• Few incorporate rural health concepts

• Rural nurses often feel disrespected by urban nurse educators

• Studies confirm that rural nurses who leave for school often don’t return

• Financial burden on rural nurses is higher

Nursing Education

• Access to and quality of on-line programs is an issue for rural nurses– Isolating, lack of support, irrelevant, repetitive– Preceptorships, residency, clinical require

expense and travel

• Nursing faculty are ill prepared to educate nurses about emerging technologies

• Few programs offer authenticity for adult learners

UMKC RN-BSN Program• On-line for the past six years• Traditionally urban focused• Uses an interactive approach (Wimba® Live

Classroom) to connect cohort group members• A developmental framework based on Covey’s

work – personal, interpersonal, human health outcomes, complex health systems

• Multiple technology supports• Team-driven practicum

The Rural Nurse Initiative

• Designed to offer the same quality RN-BSN program to rural and remote practicing nurses– Outcome goals include networking rural nurses to urban

resources such as simulation, EHR and other technologies• Rural health concepts are integrated into the curriculum• Broadband laptops provided to rural nurses and cost of

service reimbursed• 24/7 live technology support and tutoring• Re-design of the practicum• Tele-health concepts drive a live on-line health

assessment course• HRSA grant funded the program re-design and delivery

Program success

• Increase in rural nurses from approx. 10% to almost 50% of enrolled students

• Overall enrollment increase from 40 students to 250+ students in 3 years

• Almost 30% of rural graduates go on to advanced practice education

• Identified by NLN as a ‘top 10’ nursing program for use of technology

• HLC* 100% on-line certified – “a model program”• Student feedback is overwhelmingly positive• Students have extensive experience with a variety of

technology applications including tele-health concepts• Enhanced respect for rural nurses

Curriculum targeted to rural nurses

• Curriculum re-designed to integrate rural health concepts into every course – Lecture/assignments– Faculty and guest experts– Discussion boards– Applied concepts

• Content designed to compare and contrast urban and rural health issues

• Increased focus on technology applications in health care

Multi-modal technology supports

• Broadband laptops for rural nurses• Blackboard® platform with Wimba® Live

Classroom• Wikis• Wimba-based workrooms• File exchange• Instant messaging• Tutorials and orientation to the technology• 24/7 live technology support

Virtual Practicum• Virtual practicum – encompasses 9 months across

two courses utilizing virtual teams• Real projects in real communities – urban and rural• Every virtual team carefully combined with

urban/rural and near/distance students• Utilization of the multi-modal technology to manage

the virtual team project• Faculty work closely to set up projects and facilitate

student groups in the ‘consultant’ role• Technology is used to connect community partners

• Most projects have at least one student with ‘boots on the ground’

• Student teams collaborate with a health agency to identify a need, assess the target population, develop a plan of action and implement strategies and/or products designed to improve health outcomes

• Examples:

Virtual Project

• http://www.youtube.com/watch?v=3H7wG-ZhVlM

• Research based

• Collaborative

• Virtual team driven

• Attitudinal changes documented

Student comments• “Now I don’t want to let go [of the project]…”• “I had worked on projects before – nothing to this

extent. I gained so much out of it…”• “I learned how to take an idea from paper and

actually make it happen.”• “I was able to see how an effective team really can

work together to achieve a common goal.”• “I am excited to be looking at the publication of our

handbook – I would never have dreamed of this…”• “I learned that nurses truly can make a difference in

the lives of people and entire communities.”

Live on-line health assessment

• Traditional course – on-line instruction followed by 1 week of residency to practice and demonstrate skills

• Learning Exchange Reverse Demonstration© - faculty developed model using best practices in skill demonstration coupled with tele-health techniques– Student groups meet 8 times/semester on-line to

practice and demonstrate enhanced skill acquisition

– No residency requirement

• Model piloted for two semesters– Equal skill attainment with traditional course– More positive student comments for on-line instruction– Immediate instructor feedback and correction– Less cost and time commitment for students– More time and cost intensive for instructors– Prepares students to utilize tele-health constructs– Provides a method of broadly teaching a variety of

skill acquisition and enhancement to remote learners

Student supports

• On-line site to access available supportive services– Student developed based on peer feedback– Counseling/stress management– Financial aid/management– Social network/family supports– Study/Academic – Link to SON social worker

• Tutoring offered via desktop sharing (TeamViewer®)

• Technology-supported peer mentoring• Faculty/Academic Advisor mentors for

each student• 24-hour response rule for faculty• Engagement via multiple technologies• Rich media connectedness for all students• Group engagement via long-term virtual

team practicum

Faculty

• All faculty are full-time, experienced on-line educators who have demonstrated excellence

• All faculty committed to student success• Faculty are a combination of urban and rural

practicing nurses• Faculty have acute and community-based care

experience• Faculty live across the nation and model virtual

teamwork and collaborative practice with emerging technologies

• Faculty cohesion is valued• Students are treated as colleagues and

diversity of gender, ethnicity, experience and viewpoint is valued and encouraged

• Respect, responsibility, communication and excellence are the driving principles of the program

• Reasonable flexibility coupled with high expectations

How do we know it works?

• Student/employer feedback– Relevance, role expansion, positive learning

• Student learning outcome portfolios demonstrate relevant learning

• Our students are the primary recruiting tool• Recognition from our professional

organizations• Thirty percent of our students keep going!• Approximately 100 rural nurse graduates by

December, 2011.

Implications for rural health outcomes

• Nurses understand and function in an expanded role

• Collaborative, team-building and conflict resolution skills

• Leadership principles and problem-solving• Every graduate is equipped to take a

large-scale project from beginning to end• Graduates prepared for emerging

technology use

• Nurses understand principles of evidence-based practice and research fundamentals

• Aggregate health assessment and intervention skills

• Data gathering and analysis skills

• Policy and protocol development skills

• Increased awareness of emerging health issues and health care changes

• New awareness of community-based health initiatives

• Better understanding of continuum of care issues

• Exposure to innovation and creativity in health care

References

• Bennett, K., Olatosi, B. & Probst, J.C. (2008). Health disparities: A rural-urban chartbook. South Carolina Rural Health Research Center, 4. Retrieved from: http://rhr.sph.sc.edu/report/SCRHRC_RuralUrbanChartbook_Exec_Sum.pdf

• Bushy, A. (2007). Rural Nursing: Practice and issues. ANA Continuing Education Program. Retrieved from http://www.nursingworld.org/MainMenuCategories/CertificationandAccreditation/CE.aspx

• Bushy, A. (2009). A landscape view of life and healthcare, in rural settings in Handbook for rural health care ethics: A practical guide for professionals. Nelson, W. (Ed). Dartmouth College Press, N.H.

• Harkness, G.A. & DeMarco, R.F. (2012). Community and public health nursing: Evidence for practice. Philadelphia, PA: Wolters Kluwer/Loppincott Williams & Wilkins.

• Mason, D.J., Leavitt, J.K. & Chafee, M.W. (2012). Policy and politics in nursing and health care (6th ed.). St. Louis, MO: Elsevier/Saunders.