The Role of Nursing Students at Two Rural Nurse-Managed Health Clinics

With stiff competition for clinical sites, one Midwestern university partners nursing students with faculty who provide primary healthcare to clients in two rural nurse-managed clinics. Some students are also assigned to follow select clients during weekly home visit rotations for their public health clinical course. The result has been a successful faculty practice and preceptor model that benefits rural communities, a clinical setting which provides opportunities for students to experience client care needs of the underinsured or uninsured in small communities, and student exposure to the financial burdens and challenges of today’s healthcare environment in the United States. . 2 ROLE OF NURSING STUDENTS AT RURAL NURSE-MANAGED CLINICS The Role of Nursing Students at Two Rural Nurse-Managed Health Clinics It is well documented that nurse-managed clinics constitute an important part of the healthcare delivery system in the United States. A review by Coddington and Sands (2008) showed that nurse-managed clinics provide high-quality care and yield high client satisfaction. Pohl, Barkauskas, Benkert, Breer and Bostrom (2007) also found that academic nurse-managed clinics are able to provide quality care to underserved communities. Clinical settings and university schools of nursing should collaborate in the establishment of creative models for clinical education which will take into account current health and education socio-economic reforms (Dunn and Hansford, 1997). In today’s environment of growing individual and family financial constraints combined with political initiatives for cost containment of health and education resources, it is becoming increasingly difficult to provide even basic health care to patients and to sustain excellent clinical experiences for nursing education. The purpose of this article is to describe a model of nursing student involvement at two rural nurse-managed federally qualified health clinics (FQHC), which serve those who have little or no health insurance in communities which have poor access to primary care services. Background The university’s School of Nursing (SON) has a rich history of service to the north central part of this midwestern state. The school was established in 1963 and adult and pediatric nurse practitioner programs began in 2005 and 2007 respectively. The school was also among the first in the nation to admit Doctor of Nursing Practice students in a program that applies engineering principles to healthcare. 3 ROLE OF NURSING STUDENTS AT RURAL NURSE-MANAGED CLINICS In 1995, the SON’s practice opportunities and service to the community were advanced when an off-campus nurse-managed clinic was opened in response to the high incidence of inappropriate emergency room use in a nearby rural county hospital. In 2005, a survey by a local United Way in an adjacent rural community determined that increased access to healthcare was the #1 need in that area. As a result, in January 2006, the SON opened a second part-time nursemanaged clinic. The patient load in this second clinic grew quickly and it is now open full-time, due in part to the demand for healthcare in the area and in part to student collaboration with the nurse practitioners in the clinic. The clinics provide comprehensive primary and preventive health services across the lifespan, from newborns to the elderly. In 2009, the two clinics jointly obtained Federally Qualified Health Clinic status. Currently in the public health entity model, a community board, in partnership with the university, operates the clinics. Populations Served The counties with the largest populations served by these clinics report that between 1618% of the adult population are uninsured compared to the state average of 14% and the national average of 16% (Robert Wood Johnson Foundation, 2010; Kaiser Health, 2010). In 2008, poverty rates in the served counties ranged from 8.5%-11.4% compared to the state average of 12.9% and national average of 13.2% (U.S. Census, 2008). In 2007, teen birth rates (age 15-19) in the counties served range from 91-136 per 1,000 live births compared to the state rate of 110 (Indiana State Department of Health, 2007). It is important to note that Hispanic immigrants are often not included in the above data which can skew perceptions regarding the needs of the counties. Furthermore, some or all of the counties served by these rural clinics are in areas designated by the federal government as Medically Underserved Area or Population (Health Resources and Services Administration, 2010). 4 ROLE OF NURSING STUDENTS AT RURAL NURSE-MANAGED CLINICS McCann (2010) points out that community-academic partnerships have been documented as a means to bridge the gap of health disparities in underserved populations. The poorest uninsured and underinsured residents of the service area are the target population for these clinics with 62% of clients at 100% or less poverty. Many of these uninsured clients can be described as the “working poor” who do not qualify for Medicaid or Medicare. The children in the communities served are in particular need of greater access to primary healthcare, as there are no pediatricians within the local community and few within surrounding counties who will accept more Medicaid patients. A study performed by Heyman, Nunez, and Talavera (2009) found that barriers to healthcare access for unauthorized Hispanic immigrants include ineligible status for insurance or public assistance, the need for documentation to access certain healthcare segments, the fear of immigration enforcement and potential deportation, and social hierarchy. Approximately 31% of the clients served at these clinics are of Hispanic origin. Many are farm workers newly arrived from Mexico and Central America. Often, these individuals come from poor, rural areas and the adults are undereducated or illiterate and speak very little to no English. These immigrants come with little previous healthcare and subsequently many undiagnosed conditions such as diabetes, hypertension, and hyperlipidemia. A majority of these clients are unauthorized immigrants to the United States and are ineligible for any social service programs such as Medicaid or Medicare, and unauthorized children do not qualify for Medicaid or State Children’s Health Insurance Programs. The clinics are unique in the area in their bilingual capacity. These clinics have sought staff who can provide culturally appropriate care to a Hispanic population, including a bilingual secretary, registered nurse, family nurse practitioner, and translator. Health education materials 5 ROLE OF NURSING STUDENTS AT RURAL NURSE-MANAGED CLINICS are available in Spanish. Students with a language background in Spanish are highly appreciated by the client population and clinic staff as well. Health services are provided largely by nurse practitioners and students. Patients are offered a range of preventive and primary healthcare services including prenatal and pediatric care. Patients receive education, encouragement, and assistance to self-manage their illnesses. The clinics also provide chronic disease management for such conditions as diabetes, chronic obstructive pulmonary disease, hypertension, and asthma. Patients with chronic conditions are treated using established national benchmarks and clinical guidelines and evidenced-based practice. Nurse practitioners have collaborative practice agreements with an obstetrician, a family practice physician, and a pediatrician from a nearby county who review the clinics’ charts on a regular basis and are available for consultation. Role of Students The SON utilizes these clinics as sites to provide practice opportunities for faculty and clinical opportunities for students. Each semester undergraduate nursing students and nurse practitioner graduate students rotate through the clinics. Gance-Cleveland & Gilbert (2001) found that this model enhances the faculty role in the development of clinical knowledge, the conduct of clinically relevant research, and classroom instruction, and that nursing students find their classroom assignments more meaningful when they observe the information being used to serve the community, to develop grant reports, and to obtain further funding for the communities they have served. The nurse practitioners who have a professional practice at the clinics also serve as public health clinical faculty, overseeing home visit rotations. They assign select clients, many of whom have financial and transportation–related limitations but who are in need of additional follow-up 6 ROLE OF NURSING STUDENTS AT RURAL NURSE-MANAGED CLINICS care, to the students for their home visit rotations. During the weekly home health visits students provide comprehensive assessments of health and service needs. Most commonly, students assist in the management of chronic diseases, such as diabetes, hypertension, congestive heart failure, and chronic obstructive pulmonary disease (COPD). Students assess for disease status and early recognition of exacerbations. For example, students may assess and identify the onset of an upper respiratory infection, provide education and support, both symptomatic and therapeutic management for a client with COPD. Students also assist with the implementation and monitoring of the nurse practitioner’s treatment plan: initiation of new medications, monitoring for the expected result, as well as side effects, and most importantly, medication compliance. Gance-Cleveland and Gilbert (2001) found that in these clinical situations, the faculty role shifts from being the authority to a mutually supportive learning relationship. An example is when one client with untreated hypertension and carotid stenosis needed blood pressure medication with close management for side effects to prevent excessive reduction in cerebral blood flow. The client was started on medication at the recommended dose, but within a week reported a mild headache. Because of the weekly home health visits and close monitoring, the student was able to report the problem to the clinic nurse practitioner, who then reduced the dose and achieved optimal blood pressure results. Every semester, as a result of student home health visits and relationships with the nurse practitioners, patients remain compliant with recommended therapies. Students also educate the patient and involved family members on disease management, lifestyle choices, and medication, as well as reinforce previous health information given to the client by the nurse practitioner. The students are able to facilitate the plan of care with the patients in their own home environment for better outcomes. This allows care to penetrate into 7 ROLE OF NURSING STUDENTS AT RURAL NURSE-MANAGED CLINICS the patient’s environment to detect potential hazards to health and barriers to a healthy lifestyle which may otherwise go undetected. Students benefit with active involvement in the care and management of clients who have real problems and needs that are being addressed and reevaluated weekly. Patients benefit because they have contact with students, one-on-one health education and individual follow-up, all at no additional cost. Recently the senior public health nursing students have also begun to accept referrals for the clinics’ high-risk pediatric clients. Children with young mothers or new parents are being referred for weekly home visit monitoring. Specifically, referrals request that students perform environmental assessments for newborns and provide anticipatory guidance for young parents with multiple births, and single or struggling parents. Referrals are most likely to come from the surrounding small rural hospital discharge planner or the clinics’ pediatric or family nurse practitioners. These patients often benefit from young student nurses as role models. Because the students and their clients are close in age, a trusting relationship often develops quickly, as documented by Katzman, Cohen, & Lukes, 1987. As student involvement in the clinics has been established, partnerships with local health departments and schools have also been strengthened. During the recent H1N1 outbreak, students were actively involved in the administration of vaccines to the local population. Students also work closely with the local school nurses and in other community settings. Another learning opportunity in the clinics includes a senior year Capstone where undergraduate nursing students have the opportunity to work inside the clinics with a registered nurse for 100 clinical hours. Often these students chose to work in the clinic setting because of their interest in community health and working with underserved populations. These students become integral members of the clinic healthcare team. The students are able to observe nurse 8 ROLE OF NURSING STUDENTS AT RURAL NURSE-MANAGED CLINICS practitioners making decisions and managing care. This experience helps integrate previous content and allows students to utilize skills in a supportive and reinforcing environment. Allowing students to work alongside advanced practice nurses assists in forming mentoring and collegial relationships, appreciation for others' expertise, and improved understanding of the advanced practice role in nursing. The clinics also serve as a practice site for the SON’s adult and pediatric nurse practitioner students. The clinics’ nurse practitioners serve as preceptors as students learn to manage client care. The clinic nurse practitioners have a good understanding of the Adult Nurse Practitioner (ANP) and Pediatric Nurse Practitioner (PNP) curriculum and are able to help integrate the students’ learning into practice. The coordinator of the PNP program practices at one of the clinic sites and routinely serves as a preceptor for PNP students. This faculty practice model integrates didactic and clinical learning and demonstrates current evidence-based practice (EBP). Levin, Vetter, Chaya, Fieldman, & Marren (2007) found that providing education about EBP is not enough; to integrate this approach into practice, an EBP mentor makes the difference by encouraging, supporting and providing tangible assistance to the process. Studies have also shown that academic nurse-managed clinics provide a valuable experience for advanced practice nursing students. Tanner, Pohl, Ward, & Dontje (2003) found that students valued the rolemodeling of the nurse practitioner and the quality of their preceptors’ instruction. The universtiy is now beginning to explore ways to utilize the clinics as a practice and research site for DNP students. All of the nursing students assigned to rotations in the clinics are supervised by the nurse practitioners and/or SON clinical faculty. Upon hire, all clinic staff and faculty are aware of the teaching mission and agree to work with students. This partnership provides added value for the 9 ROLE OF NURSING STUDENTS AT RURAL NURSE-MANAGED CLINICS community: the clinics receive additional services and the community receives additional culturally-competent and experienced healthcare providers. Patients benefit from having additional caregivers, individual health maintenance, and personalized health education. Students benefit from increasing confidence while learning in a controlled environment with professional colleagues of varying levels and aspects of nursing education. ConclusionsThese clinics are providing a vital service in an area with limited access to healthcare. Asthe medical community in the United States struggles with providing care for the uninsured,nurse-managed clinics can be an economically sound way to provide quality primary care to thatpopulation. In addition, this faculty practice and preceptor model demonstrates and reinforcesdidactic learning and evidence-based practice in clinical nursing education. The learningenvironment is embedded in the organizational culture of teaching. Furthermore, as nursingstudents are exposed to this population they are able to better understand this important clinicalsituation, which further challenges nurses to be effective and efficient at providing high-quality,safe, and financially sound patient care. 10ROLE OF NURSING STUDENTS AT RURAL NURSE-MANAGED CLINICSReferencesCoddington, J. & Sands, L. 2008. Cost of healthcare and quality outcomes of patientsat nurse-managed clinics. Nursing Economics, 26(2), 75-83.Dunn, S. & Hansford, B. (1997). Undergraduate nursing students' perceptions of their clinicallearning environment. Journal of Advanced Nursing, 25, 1299-1306.Gance-Cleveland, B. & Gilbert, L. (2001). Connecting classroom, clinic, and community:Pediatric nurse practitioner student and faculty assessment of clinical experience atfaculty practice sites. Journal of Nursing Education, 40(4), 187-190.Health Resources and Services Administration. (2010). Find shortage areas: MUA/P by State andCounty. 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