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Life in the Frontier

The term frontier nurse practitioner (NP) is based on the notion of place as central to practice; that place is the frontier. To understand how the frontier impacts nursing practice, one must first understand the nature of life on the frontier. This chapter introduces the concept of frontier and provides definitions and demographic data specific to the concept.

A literature search using the keyword “frontier” brings up articles that involve two conceptualizations of the word. Most utilize the term frontier to describe new or cutting-edge research or practice. However, a few articles representing a less abstract meaning of the term frontier are also found. These articles refer to the frontier as a sparsely populated area—a place where either few people have traveled to or where few people live. There is a valid reason for the paucity of articles in the nursing literature that utilize the keyword frontier as a geographic designation: the term is relatively new. Prior to the late 1980s, the government classified very remote or sparsely populated areas as rural. Therefore, the differentiation between rural and frontier is a fairly new phenomenon, and the majority of extant nursing literature does not make this distinction.

The notion of a remote, sparsely populated area is the basis for the concept of frontier as utilized in this book. Frontier lands have been termed borderlands, as they lie between the last remnants of civilization and the wilderness. This term could also describe the place where frontier NPs practice: the intersection, or borderland, of nursing and medicine.

  RURAL AND FRONTIER TAXONOMIES

In 1988, Congress decided that for the purposes of health care policy, frontier is a geographic area with less than seven persons per square mile (Ricketts, Johnson-Webb, & Taylor, 1998). Although widely utilized, this definition did not take into account the effect urban areas, which may be located in larger frontier counties, have on aggregate county health data. Over the ensuing years, agencies have utilized multiple methods for determining the criteria for a frontier designation (Hart, 2012).

TABLE 1.1    1986 Rural/Frontier Matrix

Source: Elison (1986, p. 3). Reprinted with permission from Gar Elison.

In the mid-1980s, the Department of Health and Human Services (DHHS) sponsored the formation of the Frontier Health Care Task Force. This group identified specific criteria that defined the differences between frontier and rural health service areas. The resulting matrix, illustrated in Table 1.1, included driving time to next level of care, population density, and level of care at local hospitals.

Despite the 1986 matrix, definitional inconsistencies persisted. In 1997, the Frontier Education Center convened a group of experts to develop a consensus definition. The group identified three key components of the frontier designation: population density, distance, and travel time. The new matrix, Table 1.2, rates each key component and bases the frontier definition on the total score. Based on this matrix, states with the highest number of frontier counties are Colorado, Idaho, Kansas, Minnesota, Montana, Nebraska, North Dakota, New Mexico, Oklahoma, South Dakota, and Texas.

  THE FRONTIER AND REMOTE METHODOLOGY

The preceding methodologies have utilized county population statistics to delineate frontier areas. This method can be problematic, as larger frontier counties may have one metropolitan area that skews the data for the entire county. In this circumstance, one solution is to designate frontier areas by zip code, as this provides more precise differentiation of rural areas in counties with a mixture of rural and frontier areas (Bigbee, 2007).

TABLE 1.2    1997 Frontier Matrix

Note: total possible points = 105; minimum points necessary for frontier designation = 55; “extremes” = 55 to 105.

Source: Cromartie (2015).

In 2012, the Health Resources and Services Administration began accepting comments on a proposed zip code–based methodology for designating U.S. zip code areas as frontier (Health Resources and Services Administration [HRSA], 2012). The resultant frontier and remote (FAR) methodology, summarized in Table 1.3, takes into account both population density and travel time to population centers using a four-level approach. (Of note, the FAR taxonomy is one of the few methods that does not rely on a negative definition of rural, i.e., not metro.)

TABLE 1.3    FAR Criteria

FAR, frontier and remote.

Source: Health Resources and Services Administration (2012).

The codes are based on urban–rural data from the 2010 census and provide four FAR definition levels ranging from one that is relatively inclusive of rural areas (12.2 million FAR level one residents) to one that is more restrictive (2.3 million FAR level four residents). The original set of codes only considered major road networks in the travel–time calculations; however, the codes are under current revision to include local roads and ferry service (Cromartie, 2015).

The FAR methodology is an effective research tool, as it removes definitional inconsistencies in rural and frontier research. For example, the goal of this book was to elicit narrative evidence from NPs who practice in areas that are remote, where the next level of care may be 1 hour away (see Table 1.3). To this end, participants were recruited from the most remote areas, those which carry an FAR level-four designation.

TABLE 1.4    U.S. States With the Highest Percentage of Frontier Lands

Source: Frontier Education Center (2002).

  FRONTIER LANDS

The majority of frontier land lies in the western states, stretching from Montana in the north to Texas in the south, and includes up to 45% of the U.S. land mass (Nayar, Yu, & Apenteng, 2013). States with the highest percentages of frontier lands are listed in Table 1.4.

Federal lands comprise approximately 48% of the acreage of the 11 western states, and the majority of frontier land is under federal stewardship (Lorah, 2000). Seventy-seven percent of all nonmetropolitan federal land counties are found in the frontier, and 23% of frontier counties consist largely of only federal land (Frontier Education Center [FEC], 2000).

  FRONTIER DEMOGRAPHICS

In 2010, more than five and a half million people, nearly 2% of the U.S. population, lived in areas that are considered frontier (FEC, 2000). This number is declining due to population change. This change includes two major components: natural change and net migration (United States Department of Agriculture [USDA], 2015b).

Compared with urban areas, the majority of frontier counties have a higher population of older residents and a lower population of younger adults. People aged 65 and older make up 14.8% of the population in frontier areas, as compared with 12.4% in other parts of the country (FEC, 2003a, b). This high percentage is problematic, as frontier areas are less equipped to provide services and programs to meet the needs of an aging population, such as health care, assisted living, transportation, and so on.

Twenty-one of the 25 counties with the oldest population in the nation are rural. Since 2010, the increase in birth rate (natural change) has not matched the rate of out-migration (USDA, 2015a, b). Although children and youth under age 18 comprise 26.7% of the population in frontier areas, as compared with 25.7% in other areas of the county, youth tend to leave after graduation (FEC, 2003). As residents age in place and ultimately die or leave, the numbers dwindle even more until some frontier towns themselves die. The town of Fossil Oregon, county seat of Wheeler County, is an example of this phenomenon. As one resident stated, “Four deaths a month in a town of 450, the town is just going to die out” (Semuels, 2016). From 2000 to 2013, the median age in Wheeler county rose from 48 to 56, making it the oldest county in Oregon. Due to out-migration of young people, some elementary classes at the local school only have a few students. This decline in student enrollment led the school to start an online distance program to boost enrollment and keep its doors open.

  SOCIAL CAPITAL

The out-migration of young people can have a negative effect on the social capital in frontier communities. Social capital may be defined as the value that social networks and reciprocity bring to communities (Lauder, Reel, Farmer, & Griggs, 2006). Social capital is derived from the notion that social and professional connectedness is at the heart of rural and frontier communities. It is this connectedness that leads to the concept of close-knit communities. In the case of Wheeler County, the closure of the only school in town may have negative effects on its institutional social capital. School sports and drama activities garner wide support in small towns. These events cause residents to come together for common causes that benefit the students, such as ticket sales and raffles. The funds raised are used for school programs or after-school activities. In turn, these events foster reciprocity by giving the townspeople entertainment and a sense of purpose and belonging (Woolcock & Narayan, 2000).

Closure of rural and frontier health clinics also negatively impacts the social capital in remote areas. Rural health clinics bring both institutional and human social capital to their communities. Clinics employ townspeople and sometimes serve as the hub of their communities. Health professionals are often community leaders and knowledge brokers who actively participate in the social life of their communities (Schoo, Lawn, & Carson, 2016).

Nurses who work in rural and frontier areas tend to become embedded in their communities (Lauder et al., 2006). These nurses contribute not only economically to the community through personal spending and utilization of goods and services, but also socially by volunteering for organizations, working on committees, and sharing their knowledge with others. By sharing their knowledge, nurses have the capacity to increase the knowledge pool in their settings (Prior, Farmer, Godden, & Taylor, 2010).

  FRONTIER CULTURE

Culture may be defined as the behaviors and values characteristic of a particular social, ethnic, or age group. Frontier culture is a social culture that stems from geographic isolation. To cope with the challenges inherent in geographic isolation, frontier dwellers often rely on community values, collective coping mechanisms, and social cohesion (Caldwell & Boyd, 2009). The defining attributes of this culture become more evident as isolation increases (Bigbee, 1993). These attributes include a distrust of outsiders, a strong sense of independence and self-reliance, and a preference for interacting with other local residents as opposed to someone from outside the community (Bushy, 2008). This mistrust may have its roots in the long-standing exploitation of natural resources found in frontier areas (Thomas, Lowe, Fulkerson, & Smith, 2011, p. 70). Once these resources were depleted or no longer valued, many of the small towns that supported their extraction were abandoned (Brown & Shafft, 2011, p. 81). This mistrust may make it difficult for outsiders, such as new medical providers, to gain community acceptance.

Hardiness is also part of the frontier culture. This characteristic may stem from a lack of resources making improvisation the norm (Duntze, 2001). Hardiness is associated with self-reliance, the ability or desire to take care of oneself without help from others. This characteristic was observed during the destructive floods in northern California in 1997. Several small towns in the remote Sierra Nevada mountains were cut off from the rest of the state when rivers overflowed and flood waters damaged the only roads in and out of the towns. Rather than wait for help from state agencies, local residents worked together to bag sand from the riverbanks in an effort to stave off the rising waters. When help finally arrived, the locals already had the situation under control. One resident stated, “You do what you have to do to survive, you can’t wait for somebody else to come in here and do it for you” (S.F., personal communication, January 1997).

  SEASONAL POPULATION VARIATIONS IN THE FRONTIER

Seasonal population changes affect the culture of frontier communities via the influx of outsiders. National parks, national forests, national recreation areas, state parks, lands administered by the Bureau of Land Management, and other natural attractions are what draw tourists to frontier counties. These seasonal population fluctuations can overwhelm the limited resources and services in frontier areas. For example, the estimated 3 million visitors each year to Yellowstone National Park create a severe strain on the local health care system in a state of only 493,000 residents where health care provider shortages are significant. In Utah, eight tourism-dependent counties are classified as frontier counties, yet five of these have no hospital (FEC, 2003).

In addition to tourism, there are other reasons for seasonal population changes. These include seasonal tourism workers, snowbirds (north-to-south winter migrants), people who own second homes in recreational areas, and agricultural migrants. A report from the state offices of rural health supports these fluctuations. For example, in Skagway, Alaska, the winter-time population of 800 swells to accommodate 800,000 visitors and 3,000 seasonal workers in summer. Quartzsite, Arizona, a popular destination for snowbirds, can see a nearly tenfold increase in the population of its frontier community in the winter as opposed to summer. In Lake City, Hinsdale County, Colorado, the year-round county population of 760 may quadruple between June and September when summer residents arrive. Most are second home owners or recreational vehicle owners who stay on both public and private lands (FEC, 2003).

A second FEC report highlighted the effects of seasonal population variations and focused attention on the implications for frontier health care systems (FEC, 2006). The study reported that the greatest impact of seasonal populations is on emergency services and related infrastructure.

In frontier recreational areas, clinics deal with an increased number of seasonal injuries such as lacerations, sprains, fractures, and head injuries. These types of injuries test the limits of available emergency medical services that are often provided primarily by volunteers. This concept is exemplified by the following statement, made by one Minnesotan, that “ambulance crews are staffed largely by volunteers” and peak tourism season creates an “unusual burden” (FEC, 2003). In the case of Skagway, Alaska, those in need of emergency hospital services must be airlifted to facilities 1 to 2 hours away. During the summer months, this occurs on average at least once per day.

In addition to lack of emergency services, the lack of retail pharmacies in frontier areas can cause problems for visitors who often either forget to pack their prescription medications or run out during their stay. Local clinic dispensaries have limited drugs on hand and can legally only provide medications to patients who are seen at the clinic for a specific problem. Furthermore, frontier and rural pharmacies are vanishing. A National Rural Health Association policy brief (2003) found that a total of 258 rural communities with a single retail pharmacy in May 2006 had no retail pharmacy in December 2010.

  POVERTY IN THE FRONTIER

Although seasonal population variations bring challenges to frontier areas, tourism generally improves socioeconomic well-being. A study to assess this phenomenon in 311 rural counties found higher employment growth rates and a higher percentage of working-age residents who were employed (Reeder & Brown, 2005). However, in nonrecreational areas, residents of frontier communities are more likely to be poor. All 50 of the poorest counties in the United States are considered frontier, and at least half of the frontier areas have a poverty rate higher than the national average (FEC, 2003). According to the National Advisory Committee on Rural Health and Human Services, persistent poverty tends to be a rural phenomenon that is tied to physical isolation, exploitation of resources, limited assets, and limited economic opportunities. An overall lack of human and social capital leads to the most remote rural communities dealing with the biggest challenges (Duncan, 2010). Poverty is also regional, as rural poverty is largely concentrated in the south. Those with the most severe poverty are found in historically poor areas of the Southeast, including the Mississippi Delta and Appalachia, as well as on Native American lands (USDA, 2015).

Poverty is closely linked to a lack of health insurance. In 1997 and 1998, the proportion of uninsured was higher among residents of the most rural and the most urban counties than elsewhere in the United States. Nearly 21% of residents aged 65 and younger who lived in the most rural counties reported being uninsured compared with 12% of suburban residents (Eberhardt & Pamuk, 2004). Ricketts (2000) noted that rural residents are more often uninsured compared to urban residents, 18.7% versus 16.3%. In a study on social capital in Utah’s rural areas, respondents stated that lack of access to health care or medical insurance was a common experience for low-wage workers. One half of the families interviewed stated that they were uninsured, and the majority of them had accrued debts related to health conditions. Debts accrued because families earned too much to qualify for Medicaid but were unable to afford or had no access to health insurance (Gringeri, 2008).

It may take several years to discover the effect of the Affordable Care Act (ACA) on insurance coverage for frontier dwellers; furthermore, future administrations may repeal or revise provisions of the Act. Frontier residents who are self-employed or earn their living through Internet sales may earn too much to qualify for federal insurance subsidies and, therefore, remain uninsured. While the ACA may eventually be shown to have a positive effect on insurance coverage for frontier dwellers, it may also have a negative effect on access to health care, as many rural hospitals and clinics have closed their doors since its passage (Gugliotta, 2015).

  RACIAL DIVERSITY IN THE FRONTIER

In regions of the country that have higher percentages of rural non-Whites, the poverty level is higher than the national average (USDA, 2015). However, the majority of frontier counties have a percentage of non-White residents that is well below the national average of 27.6% (United States Census Bureau, 2010). Regional differences in ethnicity exist, with more Hispanics in the southern part of the United States (Rural Health Information Hub, 2010b) and more Native Americans in states with higher percentages of tribal lands such as the Dakotas, Oklahoma, and Alaska (Rural Health Information Hub, 2010a). Less than 2% of the population in rural and small town areas identifies as Native American, but more than half of all Native Americans reside in rural or small town areas (Housing Assistance Council, 2012). In addition, there are clusters of frontier counties in California and Texas that have a higher percentage of Hispanic people than the national average. During the 1990s and the post-2000 periods, the rural Hispanic population grew at the fastest rate of any racial or ethnic group, while the White population grew at the slowest rate (Johnson, 2006).

  THE FRONTIER ECONOMY

Extractive industries such as mining and timber harvesting have led to a boom–bust economy in some frontier communities. The classic examples of this phenomenon can be found in western states, where many small towns were booming at the height of the gold and silver rush, but went bust when the mining panned out. A more recent example of this phenomenon is found in northwestern North Dakota, in the Bakken Formation, where fracking has led to a modern-day oil boom.

Noonan, North Dakota, is a frontier town located near the U.S.–Canadian border, near drill sites in the Bakken Formation. Its history illustrates the concept of a boom–bust economy. Noonan’s first boom came during the railroad expansion in the late 1800s and lasted until the early 1900s, when the nation began to rely on other forms of transportation to move goods. Noonan survived the end of the rail rush due to its proximity to coal mine outcrops. A second, smaller boom fueled by coal mining lasted until the 1930s (Mayda, 2011). In the early 1990s, technological advances and rising oil prices made drilling in the Bakken profitable, and the most recent boom began. However, this boom did not last either, as the drop in oil prices has led to a recent bust in the area. For example, in April 2014, Dickinson, North Dakota, had 203 active drilling rigs. By 2015, this number had dropped to 126 (Reingold, 2015).

In frontier wilderness areas, tourism might be considered a different type of boom–bust economy, as business is said to be booming in the tourist season but a bust in the off-season. This phenomenon is seen in Graeagle, California; the town is full of tourists and shop owners in the summer months, but the red-barn-colored shops are boarded up in winter and only a small number of year-round residents can be found. In small, remote towns such as Graeagle, it may cost more money to keep the heat and lights on in the winter than can be earned with the sale of goods or services.

As with Graeagle, most frontier communities are surrounded by public lands. This has a negative effect on the tax base of these frontier areas. The federal government has recognized this and in years past has provided frontier counties with PILT (payment in lieu of taxes) funds to support services in these counties. These PILT funds are primarily utilized to fund firefighting, police protection, construction of public schools and roads, and search-and-rescue operations (Hall, 2013). However, in recent years, PILT payments have fallen below 50%, which can have a crippling effect on local economies (Todorovich & Hagler, 2009).

  CONCLUSION

Frontier communities are diverse and have characteristics that present unique challenges for nurses—challenges such as poverty, limited resources, isolation, and seasonal population variations. Frontier NPs work in areas of the country that have complex challenges, where emergency services are limited, and the next level of care is at least an hour away. This supports the concept of frontier NP practice as a high-stakes practice, owing to the complexity and severity of problems managed by frontier NPs.

Approximately 15% of all NPs practice in rural areas, with only 1.5% in frontier communities (Goolsby, 2005; Kaplan, Skillman, Fordyce, McMenamin, & Doescher, 2012). Although this number is small, their contribution is large. Not only do these NPs support the health care safety net in their frontier communities, oftentimes they are the safety net for their communities (Regan, Schempf, Yoon, & Politzer, 2003).

There is a knowledge deficit regarding frontier NP practice. Perhaps this is due to the relatively low percentage of NPs practicing in the frontier, or to the relatively new frontier designation, which distinguishes frontier as a unique subset of rural practice. The lack of published literature and the high-stakes nature of frontier NP practice support the need for a conceptual model for frontier NP practice.

  QUESTIONS FOR DISCUSSION

         •   How might isolation and distance affect the delivery and availability of goods and services to frontier areas?

         •   What types of social capital exist in your town or city and how might this compare to frontier communities?

         •   If the population in your town increased tenfold as a result of seasonal variations, how would this affect your daily life?

         •   How does poverty affect the ability of frontier residents to migrate to less rural or urban areas?

         •   How might frontier and rural areas curb the out-migration of young people?

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