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Rural Health at a Crossroads

Ironically, in a profession that proclaims to care about the needs of the underserved, and was created for that purpose, nurse practitioners as a group are not fulfilling the original mission.

Since the mid 1960's, nurse practitioner's (NP's) have been trained to provide primary care in rural communities and are hailed as pioneering leaders in the quest for lowering disparities in access to quality healthcare. The role of NP's has evolved and developed from the basic roots of rapid certification to doctoral level training and over half a century has been spent training nursing professionals how to provide excellent care for a variety of vulnerable and underserved populations. In fact, this practical vision began as an attempt to fill the gaps created by an inadequate supply of primary care physicians.1

As time passed, the results of this innovative solution were highly successful and openly embraced by the public. The services provided by advanced practice nurses have continued to grow in popularity and are currently in high demand.2 Not only do NP's deliver evidenced-based care, they also enhance care delivery through health promotion, disease prevention, and the provision of culturally-specific, literacy appropriate, patient-centered education.3 All this is delivered at an affordable rate and patient satisfaction is universally high.4

In 2011, The Institute of Medicine  report clearly supported the use of nurse practitioners as forerunners of change and recognized that these providers were capable of improving access to care, promoting distributive justice, and establishing equity for communities in need.5 At the height of the healthcare reform debate, President Obama publically recognized NPs as a vital component needed to reduce health disparities. During his administration, he supported the apportionment of millions of dollars in financial support for the growth and development of nurses as leaders in health care reform; however, there continues to be a lack of interest and commitment to serving in rural communities from the current generation of nurse practitioners as well as physicians.6

Ironically, in a profession that proclaims to care about the needs of the underserved, and was created for that purpose, nurse practitioners as a group are not fulfilling the original mission. Although the number of NP's practicing in rural communities varies greatly from state to state, most NP's are not working to lower disparities by serving in communities that lack a sufficient number of care providers.7

SEE ALSO: An Iterative Approach to Population Health

Rural Healthcare Gaps
According to the American Academy of Family Practice, rural communities  continue to suffer from a lack of primary care physicians and certain social determinates play a significant role in their choice of employment location. Contributing factors have been cited as pertaining to the needs of the provider's family like schools, recreation, income potential, spouse employment options and willing consent from spouses to live in a rural area.8  As primary care providers, NP's face the same dilemmas for themselves and their families.

Interestingly, this problem is not a new one. Lin, Burns, and Nochajski reported that a large majority (85.04%) of nurse practitioners practiced in metropolitan areas, and only a few (14.97%) in the rural communities across the United States.9 In addition, the Agency for Healthcare Research and Quality (AHRQ) noted that not much has changed in geographic distribution since 1994. AHRQ (2012) reported that a large number (84.4%) of NP's currently work in metropolitan areas and only (15.6%) of those work in rural areas.7 These statistics highlight a disconnect between the application of what the NP  role was originally intended to do and what NP's have decided to do with the skills they have acquired.10

All across the nation, states are debating the scope of practice for nurse practitioners (NP's). Legislators and nursing advocates are discussing how to define practice authority and the role of advanced practice nurses.2 As these dialogues rage on, many Americans continue to go without primary health care and are denied the access to health services that NP's should be able to provide. With the ever growing number of patients in need of affordable, quality healthcare, the barriers to professional practice and utilization must be addressed.11 

Changing Attitudes Among NPs
Furthermore, NP's as a group must take a critical look at where we are going as a profession and honestly espouse who we are and who we aspire to be. Most importantly, we must evaluate our current and future role in health care and contemplate what it will take to move the country forward medically and concurrently meet the needs of society at large. We must ask ourselves the hard questions associated with embracing and creating practical and sustainable solutions to the misdistribution of healthcare delivery and inequality of services rendered. 12

In order for NP's to truly meet the healthcare needs of the underserved and underrepresented citizens of our nation, we must honestly analyze the problems, identify the barriers, and cultivate solutions based on the truth as it evolves and not conjecture or political rhetoric. NP's must determine if we are choosing to practice in urban communities instead of rural ones because of the quality of life associated with the conveniences, educational opportunities, employment options, and recreation as well as entertainment choices found in a large city for us and our families.12  We must assess our current and future career motives and diagnose the underlying realities for seeking full scope of practice. 

We need to introspectively evaluate ourselves and acknowledge if we are inspired to effect change in legislation in order to provide care for the underserved populations we were originally developed to assist or do we simply want to be recognized as autonomous providers, maximize our financial compensation, acquire greater job security, and advance the profession of nursing.13 Because the statistics overwhelmingly demonstrate the heavy distribution of NP's in metropolitan areas, it is hard to imagine how improving scope of practice will significantly change the paradigm.7 

Meeting the Needs of Underserved Communities
On the other hand, if we can come to an agreement among ourselves about who we are and what we really want, we can be more effective at gaining the support we need to do the advanced practice work we desire, and if we can put away any pretense that is standing in the way of progress, we can be more effective at meeting our legislative goals. Ultimately, we can then begin to truly address how to characterize and clarify our needs as care providers and collaborate more fully with each other as well as the medical community at large to meet the needs of underserved communities. 

By acknowledging and defining NP roles, boundaries, and professional aspirations as well as establishing a precise agenda for professional development, NP's can create the foundation needed for effective legislative change. Because nursing is the largest of all medical professions, we can be a powerful force if we work together to accomplish our goals. It is vital to the mission of advancing nursing policy for nurses to unite, actively participate in the legislative process, engage in professional organizations, and write letters of support to key congressmen.

 We must purpose to stay current and knowledgeable about the new laws and proposed bill changes that saturate the legal system. NP's should also get involved in local political campaigns and develop relationships with local representatives. Most importantly, we should create a consensus about what we are trying to achieve and understand the reasons why, as well as study the issues, know the facts, and let our collective voice be heard.14


1.  Keeling, A., W., Historical Perspectives on an Expanded Role for Nursing. OJIN:  The Online Journal of Issues in Nursing, 2012; 20 (2), Manuscript 2. doi: 10.3912/OJIN.Vol20No02Man02

2.  National Governors Association. The Role of Nurse Practitioners in Meeting Increasing Demand for Primary Care.,%202012. Accessed June 5, 2016.

3.  American Academy of Nurse Practitioners. (AANP). Position Statement & Papers. Retrieved from  2012-2016. Accessed June 6, 2016.

4.  Staff Care. NP Job Outlook: Nurse Practitioner Demand at All-Time High. Retrieved from  Published February 4, 2016. Accessed June 6, 2016.

5.  Institute of Medicine (IOM). The Future of nursing: Leading the change, advancing health. Washington, D.C.: The National Academies Press; 2011.

6.  The White House. The Obama Administration's Record on Supporting the Nursing Workforce.  Published date unknown. Accessed June 6, 2016. 

7.  Agency for Healthcare Research and Quality (AHRQ). Primary Care Workforce facts and stats No. 3.  Published January 2012. Accessed June 6, 2016.

8.  American Academy of Family Medicine.. Rural Practice, Keeping Physicians In (Position Paper). Retrieved from  Published 2016. Accessed June 6, 2016.

9.  Lin, G., Burns, P.A., & Nochajski, T., H. The Geographic Distribution of Nurse Practitioners in the United States. Applied Geographic Studies; 1997, Vol. 1, No. 4, 287-301.

10.  American Academy of Nurse Practitioners. (AANP) Nurse Practitioner State Practice Environment. Retrieved from  2012-2016. Accessed June 6, 2016.

11.  Skillman, S.M., Kaplan, L., Fordyce, M. A., McMemamin, P. D., & Doescher, M. P. Understanding Advanced Practice Registered Nurse distribution in Urban and Rural Areas of the United Sates Using national Provider Identifier Data.  Published February 2012. Accessed June 6, 2016.

12.  Journal of American Medical Association. Physicians with highly educated spouse less likely to work in rural underserved areas.  Published March 2016. Accessed June 6, 2016.

13.  Nurse Journal. 15 reasons to become a family nurse practitioner. Published 2015-2016. Accessed June 6, 2016.

14.  Ryan, S., F., & Rosenberg, S. Nurse Practitioners and Political Engagement: Findings from a nurse practitioner advanced practice focus group & national online survey. Robert Woods Johnson Foundation.  Published February 2015. Accessed June 6, 2016. 

Virginia Borders is an assistant professor at Augusta University's College of Nursing. She also works as a family nurse practitioner at the Druid Park Community Clinic in Augusta, Georgia, where she serves the underinsured in her community.

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There is no training that can meet the needs of underserved areas. This is entirely about six degrees of lesser payments going to the 2621 counties lowest in physician and clinician workforce where there are concentrations of the four types of patients with least supportive payments - Medicaid, high deductible, Veteran, and Medicare. These patients are often missing from support of local workforce (high deductible, Veteran), or have payments below the cost of delivery (Medicaid, Medicare, some insurance).

These 2621 counties have grown fastest in population over 5 decades to become 40% of the population including 75% of the rural population (45 million) and 32% of the urban population or 86 million - but have 43 - 45% of poor, elderly, poor children, Medicare, Medicaid populations and 42 - 45% of Social Security, SNAP, and disability payments.

Health spending specific to these counties is only about $3500 per person per year compared to $10000 for the average and $29000 per person in the top concentration settings. The top 10% of the population in physician concentrations have 150 residents in training per 100,000 - significantly more than the 115 active physicians per 100,000 in lowest concentration counties.

The more complex populations have higher proportions of diabetes (47%), preventable diseases, obesity, smoking, binge drinking, and fair to poor health status.

They were not lacking in unemployment or in health insurance coverage - they just have the worst jobs and worst insurance types.

Only the MD DO NP and PA active graduates found in family practice positions have 36% found in these counties with 40% of the US. Only family practice has population based distribution to go with lowest payments and rapidly increasing complexity and demand with declining support. Not surprisingly the payment designs and punishing regulations have resulted in increased costs of turnover, recruitment, retention plus declining morale and productivity. Not surprisingly for decades the proportions of MD DO NP and PA found in family practice positions has steadily fallen as other specialties receive more dollars for their services.

Generalists and general specialties are 70% of local workforce where needed and 90% of the services - and no training design can overcome the financial designs based on cost cutting, stagnant pay, and accelerating costs of delivery.

Robert BowmanJanuary 10, 2017
Gilbert, AZ


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