13

Recommendations and Conclusions

Part I of this book paints a picture of life in the frontier for both frontier dwellers and frontier health care providers. This picture includes challenges regarding the provision of health care in the frontier. Part II provides examples of how frontier communities and nurse practitioners (NPs) are meeting these challenges and, in some cases, overcoming them. These challenges include workforce, emergency medical services (EMS), and educational issues. The conceptual model for frontier NP practice provides guidelines, or recommendations, in each of these areas. This chapter begins with a review of these guidelines.

  NURSING EDUCATION

There are two recommendations from the Institute of Medicine’s report on the future of nursing that have implications for frontier NP education (Institute of Medicine (US), Committee on the Robert Wood Johnson Foundation Initiative on the Future of Nursing, 2011). First, identify the features of online, simulation, and tele-health nursing education that most cost-effectively expand nursing education capacity. Second, identify and test new and existing models of education to support nurses’ engagement in team-based, patient-centered care to diverse populations, across the life span, in a range of settings.

To prepare nurses to work in the frontier setting, the challenge is twofold. First, identify and recruit candidates who are likely to practice in the frontier. This includes developing online and hybrid programs that allow students who live in frontier communities to receive the bulk of their education while staying in these communities. The second challenge is to develop educational programs that prepare NPs for the distinct type of practice conceptualized in the model. Based on the narrative evidence underlying the model, the following recommendations are presented:

       •   Frontier NPs provide primary and emergency care to patients of all ages. Therefore, to practice in frontier communities, NPs must be prepared as family NPs. This licensure allows the broadest scope of practice.

       •   Mental health services are severely lacking in frontier communities. Frontier NPs need the knowledge required to treat mental health patients safely and effectively.

       •   Trauma care is inevitable in the frontier. NP programs may not be accredited to provide training in this area. Therefore, NP programs should educate students regarding this aspect of frontier practice and provide suggestions for where NPs can receive this preparation.

       •   Professional isolation is common in the frontier. Preparing students to use both formal and informal resources is paramount to reduce the effects of this isolation.

       •   Most frontier NPs have on-call obligations that can be challenging both professionally and personally. NPs who wish to practice in the frontier require strong mentorship from a provider who has developed the means to cope with these challenges.

       •   NPs who wish to practice in the frontier should be educated on the various federal and state programs that affect frontier NP practice and the delivery of frontier health care.

       •   Ethical content should include the ethics of availability and ethical comportment when dealing with life-and-death situations in the frontier. Leadership and advocacy in frontier settings are issues that can be discussed and promoted within an ethical framework.

Some participants in this book were prepared in NP programs whose mission was to educate NPs for rural practice. None of the participants received any specialized education regarding rural or frontier issues. Course content in rural NP education tracts should support an expert-generalist skillset; courses could provide content regarding several issues related to rural/frontier health care:

       •   Rural/frontier demographics

       •   Rural/frontier culture

       •   Health status/disparities

       •   Rural/frontier economies

       •   Rural/frontier health issues, specifically related to extractive industries and agriculture

       •   Adequacy or availability of rural/frontier public health

       •   Rural/frontier health care delivery models

       •   Effect of the Affordable Care Act (ACA), specifically regarding rural accountable care organizations and value-based payment systems

       •   Research on rural and frontier nursing

Although this is not an exhaustive list, it recognizes the distinctive nature of frontier nursing. Depending upon the local industries, programs could also provide intensive experiences to prepare students for the most common industrial-related injuries in their geographic setting.

  RESEARCH

The model provides a framework for research involving various aspects of frontier health care delivery. The outcome, less reliance on emergency departments for care, could be determined by chart audits and a review of after-hour cases seen by the NP. For example, the electronic medical record system tracts both the time of day a patient was seen and the type of visit. A researcher could audit the after-hour visits to determine the number of patients who avoided emergency department visits due to the availability of local care. If it could be proven that significant health care dollars were saved, some of those funds might be utilized to offset the cost of paying an on-call provider.

Ann noted that often patient emergencies could be managed at her clinic without extended transport times and the increased cost of an acute care emergency room. The outcome, integrated emergency response, might involve an audit of run reviews to determine how quickly emergency patients received initial care, by whom (what skill level), and the length of transport time to definitive care. This time might include transport time to a trauma center, local hospital, or a rural clinic. An investigation of this type might also determine what percentage of time a community was left without the available ambulance services, a phenomenon that occurs in the event of long transport times. Results could lead to expanded or new agreements for mutual coverage by other agencies.

Interventional studies are also an option. For example, providing relevant and convenient continuing education on topics such as medical treatment for depression could improve management of patients in frontier areas. The effectiveness of the intervention could be demonstrated through the use of patient pre- and postintervention depression scores.

Organizations interested in frontier workforce retention could survey frontier providers regarding their intent to stay in frontier practice. For those providers who indicate a desire to leave, the model could provide a framework to determine what causal factors were included in their decision-making process. Through ameliorating reversible factors, some practitioners could potentially decide to stay in frontier practice. For example, efforts to bring in a relief provider for a few days a month might relieve enough stress to allow a provider to stay in the community.

  HEALTH CARE POLICY

Frontier Health Care Workforce

Chapter 2 presented evidence that recruitment and retention of frontier providers are problematic. Chapter 3 presented research regarding recruitment schemes and retention theories. The literature suggests that being close to family or having been raised in a rural area enhanced recruitment and retention of frontier providers. In particular, Sharp (2010) listed proximity to family as a likely reason for nurses to stay in rural/frontier areas.

There are also recruitment strategies, such as loan repayment models, mentioned in the review. The literature is also rife with information regarding rural rotations and immersion experiences for nursing and medical students. However, participants in this book came to the frontier for the following reasons:

       •   A desire for autonomy and independence

       •   To provide a service in communities where they were raised (grow your own)

       •   To be near family

       •   For the lifestyle

There may be personality characteristics that are predictive of successful rural or frontier NP practice. In Colledge’s (2000) study of hardiness as a predictor of NPs in rural practice, she found that hardiness did not predict success in rural areas. However, Colledge did find that nurses who scored higher on the challenge subscale were more likely to practice effectively in rural/frontier areas. Challenge may be related to the constructs of autonomy and independence, reasons cited by participants as a motivation to enter frontier NP practice. Therefore, nursing schools may want to explore personality traits when considering applicants for rural/frontier tracts.

National Health Service Corp (NHSC) loan repayment commitments are offered for 2-year terms of service. Although this commitment exposes NPs to the frontier/rural practice environment, it does little to encourage retention. The participants in this book had experience with four such NHSC loan repayment recipients. None of the four stayed past their 2-year commitment. Family reasons were most commonly cited as reasons for leaving. However, this should not be taken to indicate that the program has no merit. Although the NHSC loan repayment program did not provide long-term coverage for the frontier clinics involved in this study, it did provide short-term coverage solutions and respite for the NPs who worked with them. It also provided recipients experiences in patient situations not likely to be found elsewhere.

An evidence-based solution to this problem would seem to be the grow-your-own model. A recent study demonstrated that all frontier counties in the study’s data set had at least one RN (Jakobs, 2014). RNs living in frontier communities who desire to further their education should be encouraged and supported to do so. These RNs could be supported by educational grants and loan repayment programs such as the NHSC. Educational opportunities that combine distance education with local preceptorships would support this concept. Programs such as the RN to Doctor of Nursing Practice (DNP) could fast-track these students.

Emergency Services

The narrative evidence in this book paints the picture of a very fragile and fragmented frontier EMS system. This finding supports a previous study of EMS in rural areas of this country. That study indicated that frontier EMS systems have difficulty staffing and recruiting enough volunteers to provide timely patient transport to emergency or trauma departments (Knott, 2003).

The availability of air transport does not entirely mitigate these issues. The participants in this book stated that there was a minimum of 35 minutes to an hour for air transport to reach the scene of the emergency or to a safe landing zone. Air transport may also be hampered by poor weather conditions. Additionally, geographic conditions may necessitate the availability of ambulance services to transport patients to a safe landing zone.

Transport times may also be lengthening due to the increase in rural hospital closures, resulting in longer transport times from frontier communities to the nearest emergency department. The National Advisory Committee on Rural Health and Human Services recently published a policy brief to address the loss of rural emergency departments (2016). The committee proposes several alternative models to preserve access to emergency care. One option, or alternative model, was proposed for communities that are too small to support a 24-hour emergency department; it is consistent with some characteristics of the participant models in this book. This option includes the creation of a primary care clinic that would be open 8 to 12 hours a day with an adjacent ambulance service operating 24/7, creating a clinic by day, and a stabilize-and-transfer model by night. Medicare could reimburse primary care visits and ambulance transports, but also provide a fixed supplemental amount to support the capital costs of operating a primary care practice, the standby costs of the ambulance service, and costs of uncompensated care. The committee recommendations support the notion that NPs and their respective frontier clinics should be considered part of the prehospital system in their local communities or regions.

The experiences of participants in this study indicate poor formal integration with local EMS systems. This is unfortunate for a variety of reasons. First, in communities where only basic life support (BLS) services are available, the local NP is most likely the highest trained health care provider available and may represent the only advanced care life support within a 50- to 150-mile radius. Second, it has been the experience of several participants in this inquiry that trauma and cardiac patients present themselves directly to clinics—clinics that do not carry life-saving medications. Lastly, in frontier areas, the golden hour can be lost through the amount of time it takes to get volunteer EMS personnel to the scene. NPs can mitigate at least part of this lost time by stabilizing trauma and cardiac patients prior to transport.

Evidence in this book illustrates that NPs are providing trauma and emergency medical care in frontier clinics across the country. Evidence in the literature also illustrates that trauma and cardiac patients are dying in frontier areas due to a lack of timely, integrated care. The model offers the following guidelines related to the integration of life saving EMS in frontier communities:

       •   NPs should be recognized and integrated into the EMS system

       •   24/7 on-call coverage by a provider who holds advanced cardiac life support (ACLS) certification

       •   ACLS medications on the ambulance and in the clinic

       •   An alternative base station status for the EMS-integrated frontier clinics; this would allow patients to be transported to the clinic, if necessary, and be stabilized prior to further transport

       •   Reliable communication systems between volunteers, clinic, and tertiary hospital

       •   Available local x-ray services

       •   Volunteer EMS personnel should be given an alternative scope of practice that allows for insertion of IVs and the provision of IV fluids, epinephrine, and albuterol under specific standardized protocols or while under personal or radio supervision by the NP

As noted in Chapter 1, most frontier communities are surrounded by public lands. This has a negative effect on the ability to fund EMS systems in 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; however, this funding has decreased over recent years (U.S. Department of the Interior, n.d.).

The narratives also indicate a shift in health care funding. This shift appears to be away from communities that experience spatial health care inequity and toward population centers. Thus, frontier communities may interpret this as federal abandonment of frontier counties in this country, counties where most of the land is held in public trust. The funding and staffing of integrated frontier health care models takes creativity, tenacity, and federal support. It is important that this occurs, because the reality of the frontier EMS system is that you may dial 911 and no one comes to help you.

  RECOMMENDATIONS FOR FURTHER RESEARCH

There is a paucity of research regarding frontier NP practice and frontier health care in general. Recommendations for further research are based on the narrative evidence presented in this book. Embedded in the recommendations for further research is the notion that NPs are inexplicitly involved with frontier health care. The participants in this book were all older than 50 and worried about their replacement. This is a valid concern and one that is worth further exploration.

Further research into the distribution of both rural and frontier NPs is warranted, as the last survey of NPs was conducted in 2000. To adequately conduct frontier nursing research, an updated survey of rural NP distribution should be conducted using established rural and frontier criteria. Some state boards of nursing report the distribution of advanced practice registered nurses (APRNs) within their state, but do not list the specific category of APRN, such as NP. The same situation exists when conducting a zip-code search using national provider identifier (NPI) numbers. The NPI does not distinguish an NP from an APRN. With the expansion of electronic billing and electronic medical records, researchers may have the opportunity to develop an accurate method to determine frontier NP distribution.

Further exploration into the economic impact that frontier clinics have on their community is warranted. Funding priorities are shifting to both population-based models and evidence-based models. Further studies to determine the amount of money and valuable emergency department resources saved when frontier patients are treated locally would support subsidizing 24/7 medical coverage in frontier communities.

The diversity of clinics and settings in this book illustrate the point that it is not feasible to have a one-size-fits-all model for the delivery of frontier health care. This statement is supported by the National Advisory Committee on Rural Health and Human Services, which states that no single model will fit all rural/frontier communities (2016, p. 8). Further research to determine which model best fits with the needs of specific communities would be beneficial.

  CONCLUSION

The model in this book provides a guide for frontier NP practice from an emic, or insider, perspective. The participant narratives represent the reality, or ontology, of frontier NP practice. It is the assumption of this book that frontier NP practice is distinct from practice in other settings, a distinctive practice that few are aware of. The conceptual model for frontier NP practice, which resulted from participant narratives, is a guideline for practice, education, research, and policy into this distinct practice.

Frontier NPs provide a vital link in the overall scheme of frontier health care in the United States. Furthermore, NPs must have specific knowledge to practice effectively in frontier settings. To withstand the shifting sands of federal and state policy, frontier NPs must be informed and united in their cause: the cause of providing access to primary and emergency health care in frontier settings. The goal of this book is to give voice to NPs who are working in remote, isolated areas of the country. It is vital to the future of frontier health care that this chorus of voices be heard.

  QUESTIONS FOR DISCUSSION

         •   What would be an ideal model to prepare NPs for frontier practice?

         •   What further recommendations could be made based on the participant narratives?

         •   Some people may suggest that frontier communities fund their own EMS system. Do you believe this is plausible? Do you believe this is ethical?

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