NEW N E W H O R I Z O N S
How clinical nurse leaders can
improve rural
By Tammy L. Rogers, MSN, RN-BC, CMSRN, CNL, and Cheri R. Darden, MSN, RN-BC, CNL
Why CNLs? In response to the changing healthcare environment, the CNL role was developed to provide an advanced nursing generalist who’s specially educated to manage patient care and enhance outcomes. CNLs have completed not only graduate-level coursework and clinical expectations, but they also demonstrate expertise in their role through specialty certification from the Commission on Nurse Certification. As the American Association of Colleges of Nursing describes in the Competencies and Curricular Expectations for Clinical Nurse Leader Education and Practice, CNLs function in many roles.1 (See CNLs wear many hats.) CNLs provide a distinct perspective for the delivery of complex patient care by not only managing a patient case load but also analyzing and interpreting data for outcomes improvement, providing staff education and professional development, and creatively delegating and overseeing both human and fiscal resources. In collaboration with the interdisciplinary team, CNLs assess specific clinical microsystems to identify and implement evidence-based interventions that improve healthcare delivery and patient outcomes.2 (See What’s a clinical microsystem?) Indicators of improved patient outcomes may include decreased length of stay, improved patient safety, fewer inpatient admissions, and enhanced patient health knowledge.
52 l Nursing2014 l September
LAKOVK ALININ ANDL ORDR UNAR /iSTOCK
PATIENTS LIVING IN RURAL SETTINGS may find that many hospitals are in far-away urban areas. Patients are being discharged sooner than ever, many with complex health issues that need to be managed in outpatient settings, far beyond hospital walls. Empowering these patients to become the primary stakeholders of their own care in their own environment can enhance patient-centered care. Graduate-level clinical nurse leaders (CNLs) are RNs whose education has given them a solid foundation in nursing organization and policy, leadership, outcomes, and care management. This prepares CNLs to be effective change agents by helping nurses who work in rural areas increase patients’ access to healthcare. This article describes how CNLs can improve access to healthcare for patients living in rural areas along with the many nurses in various other roles who are already providing expert care.
www.Nursing2014.com
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
healthcare
www.Nursing2014.com
September l Nursing2014 l 53
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
In a rural setting, CNLs can decrease patients’ need for travel to a distant clinic or hospital, reduce the distress of travel, and decrease associated medical costs while enhancing the clinical services provided. Nurses already working in rural healthcare should consider getting the further education needed for this role. Increasing access A primary barrier for rural dwellers seeking healthcare is accessibility. As a CNL begins working with these patients, an initial focus is to increase access by bringing point-ofcare services to patients rather than expecting them to travel to a major healthcare center. Critical access hospitals (CAHs) are designated rural community hospitals receiving cost-based reimbursement from Medicare to facilitate services to areas where these services would otherwise be fiscally impossible.3 Many of these CAHs are limited in patient census and maximum length of stay, further increasing the need to reduce admissions and improve the overall health of the rural population.4 The CNL may be able to use some CAH resources, such as office space, computers, or telephones, as a base for reaching out to this underserved population. The CNL is likely to be an employee of the CAH itself rather than a rural clinic due to budget constraints and fiscal limitations. Improving patient education Health promotion and disease prevention education are vital to the well-being of patients in rural settings. Important topics for education include chronic disease management, prenatal care, reproductive health, alcohol and tobacco cessation, fall prevention, and medication safety. All rural nurses should identify patients with limited health literacy so that they can tailor patient education appropriately. Health illiteracy is associated with older age, low socioeconomic status, minority status, cultural or language barriers, and less than a high school education.5,6 54 l Nursing2014 l September
What’s a clinical microsystem? A clinical microsystem is a small group of patients and the professionals who regularly care for them.2 Often, these smaller groups are part of larger institutions or systems and are composed of people with similar needs.11 In a rural setting, clinical microsystems may be primary care clinics, remote hospitals, or even mobile healthcare teams. According to Nelson and colleagues, microsystems are living units that continuously evolve over time, yet always maintain a central focus on the patient.2 Microsystems are everywhere, at all levels of healthcare delivery, and may include family practice clinics, dialysis centers, home healthcare teams, and extended-care facilities.2
Those with limited health literacy may benefit from alternate methods of education; for example, telephone or videoconference sessions if available. (See Signs of low health literacy.) Try traveling clinics CNLs should also consider implementing small “traveling clinics” to provide information and perform some tasks that might otherwise require rural patients to travel long distances to healthcare centers or hospitals. Organized on a routine schedule, these traveling clinics journey to rural community centers, schools, churches, or other meeting places to bring specific services and health education to underserved patients. Nurses, including the CNL, can monitor vital signs, obtain blood specimens for routine lab work, perform wound care and other procedures, and administer immunizations. They may also teach patients to operate medical equipment such as home vital sign machines or telehealth scales and glucometers as well as provide other health education. Rural health nurses can also monitor and evaluate data collected during traveling clinic
CNLs wear many hats1 • • •
Clinician
• • • • • •
Educator
Outcomes manager Advocate for patients, staff, and communities Information manager Coordinator of patient care Risk anticipator Team manager Steward of resources.
visits, including attendance and type of intervention performed to ensure future improvements best serve the unique needs of the rural population.7 Tracking results, expanding scope Outcomes can best be measured through improved data points, such as decreased admissions, reduced length of stay, decreased readmissions, decreased fall rates, and increased home health referrals.4 These data should be tracked and analyzed at least quarterly to determine trends and variances in areas that require more intense focus. Using electronic medical record systems in rural healthcare settings significantly streamlines processes, easing the CNL’s workload and increasing efficiency. CNLs will need to perform assessments of the microsystem, including assessments of both patients and clinicians and of available resources. The CNL can assist amenable healthcare staff in the microsystem to develop specific competencies by providing or facilitating education to update their knowledge and skill set. As indicated by Strasser and Neusy, resource limitations in the rural setting include not only a lack of healthcare providers, but variable skill level of those who are present.8 Through the implementation of these interventions, CNLs assume the roles of patient advocate, clinician, educator, and outcomes manager. They anticipate risks to the overall health and wellness of the rural microsystem, overcoming barriers such as lack of insurance or limited financial means, transportation difficulties, www.Nursing2014.com
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
comorbidities, and insufficient preventive services. Unique challenges The success of these interventions will be largely based on the amount of community involvement. Collaboration with local healthcare providers and community leaders is key. Many formal and informal local leaders provide access to the trust of closely knit rural communities and suggest local meeting places that outsiders may miss. These essential advisors may assist in overcoming language barriers and function as culture brokers, helping CNLs to navigate complex family and community relationships. Interaction with these leaders may boost attendance at scheduled events and enhance patients’ willingness to participate in new services. Literature and announcements must be widely distributed using the Internet and various other resources. For example, radio and TV announcements can be effective, as can flyers posted at local gathering places such as churches, food stores, town halls, and post offices. Healthcare providers must recognize the cultural differences between urban and rural groups. Rural dwellers tend to be very resilient, have strong social networks, and be exceptionally self-reliant. Recognizing these particular characteristics as part of an ongoing assessment is imperative as they may actually increase the potential for certain disease states among rural inhabitants.4 Specifically, the Rural Health Research and Policy Centers reported that rural dwellers were more likely to experience poor health status, obesity, diabetes, and limitations in activity when compared with urban residents.9 Rural communities tend to have limited access to healthy living options such as gyms and a culture of high-fat dietary choices. Previous generations offset high-fat diets with physical labor that technology has, in many cases, made obsolete. Relative isolation from medical care combined with strong self-reliance www.Nursing2014.com
Signs of low health literacy12,13 Many patients who struggle with health literacy:
• •
miss scheduled visits.
•
create excuses to refrain from writing on documents during the appointment.
•
claim vision difficulties when reading in front of providers.
• •
ignore or misunderstand instructions.
ask to take forms home to complete them.
ask to sign paperwork with a thumbprint.
inhibits many from seeking preventive healthcare or early intervention.10 Patients in the rural clinical microsystem use a diverse array of technological resources. For tech-savvy patients with Internet access, encrypted e-mail and web-based education can greatly improve access to healthcare and adherence to treatment. Although they’re nearly ubiquitous in urban settings, smart phones or computers may not be as useful in rural areas due to network limitations or personal concerns, such as privacy, inability to afford service, and even technophobia. Many in rural areas rely instead on mail, telephone, and conversation among neighbors for information. For these patients, using telephone-moderated health assistive devices can maximize the rural healthcare experience. For instance, home placement of peripheral devices such as weight scales, sphygmomanometers, blood glucose monitors, and stethoscopes that are connected to telehealth equipment let nurses monitor clinical signs remotely. Even if they’re not up on the latest technology, most patients have access to a telephone, providing opportunities for follow-up and education. Visiting home health nurses can also improve outcomes by assessing patients in person, asking them to demonstrate personal care skills, and educating them about risk reduction, health promotion, and disease management.
Broad reach CNLs can utilize their education and skill sets to improve rural health through many routes. Patients who live far from hospitals in remote areas can only benefit from CNLs’ expertise and care. ■ REFERENCES 1. American Association of Colleges of Nursing. Competencies and Curricular Expectations for Clinical Nurse Leader Education and Practice. 2013. http:// www.aacn.nche.edu/cnl/CNL-CompetenciesOctober-2013.pdf. 2. Nelson EC, Batalden PB, Godfrey MM. Quality by Design: A Clinical Microsystems Approach. San Francisco, CA: Jossey-Bass/Wiley; 2007. 3. American Hospital Association. Critical Access Hospitals. 2013. http://www.aha.org/advocacyissues/cah/index.shtml. 4. Jukkala A, Greenwood R, Ladner K, Hopkins L. The clinical nurse leader and rural hospital safety and quality. Online J Rural Nurs Health Care. 2010;10(2):38-44. http://rnojournal.binghamton. edu/index.php/RNO/article/viewFile/45/45. 5. Berkman ND, Sheridan SL, Donahue KE, Halpern DJ, Crotty K. Low health literacy and health outcomes: an updated systematic review. Ann Intern Med. 2011;155(2):97-107. 6. Shipman JP, Kurtz-Rossi S, Funk CJ. The health information literacy research project. J Med Libr Assoc. 2009;97(4):293-301. 7. Tham R, Humphreys J, Kinsman L, et al. Evaluating the impact of sustainable comprehensive primary health care on rural health. Aust J Rural Health. 2010;18(4):166-172. 8. Strasser R, Neusy AJ. Context counts: training health workers in and for rural and remote areas. Bull World Health Organ. 2010;88(10):777-782. 9. Bennett KJ, Olatosi B, Probst JC. Health Disparities: A Rural-Urban Chartbook. Columbia, SC: South Carolina Rural Health Research Center; 2008. http://rhr.sph.sc.edu/report/(7-3)%20Health%20 Disparities%20A%20Rural%20Urban%20 Chartbook%20-%20Distribution%20Copy.pdf. 10. Befort CA, Nazir N, Perri MG. Prevalence of obesity among adults from rural and urban areas of the United States: findings from NHANES (2005-2008). J Rural Health. 2012;28(4):392-397. 11. Institute for Healthcare Improvement. Clinical Microsystem Assessment Tool. 2014. http://www.ihi.org/resources/pages/tools/ clinicalmicrosystemassessmenttool.aspx. 12. Agho AO, Deason LM, Rivers PA. Provider perceptions of health literacy in an urban community. Int J Health Promot Educ. 2011;49(2): 36-43. 13. Eggertson L. Health literacy: more than just the three Rs. Can Nurse. 2011;107(1):18-23. RESOURCE The Joint Commission. Health Care at the Crossroads: Guiding Principles for the Development of the Hospital of the Future. 2008. http://www. jointcommission.org/Guiding_Principles_for_The_ Development_of_the_Hospital_of_The_Future_. Tammy L. Rogers and Cheri R. Darden are nurse educators at Central Texas Veterans Healthcare System in Temple, Tex. The authors have disclosed that they have no financial relationships related to this article. DOI-10.1097/01.NURSE.0000452994.18665.57
September l Nursing2014 l 55
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
How clinical nurse leaders can
improve rural
By Tammy L. Rogers, MSN, RN-BC, CMSRN, CNL, and Cheri R. Darden, MSN, RN-BC, CNL
Why CNLs? In response to the changing healthcare environment, the CNL role was developed to provide an advanced nursing generalist who’s specially educated to manage patient care and enhance outcomes. CNLs have completed not only graduate-level coursework and clinical expectations, but they also demonstrate expertise in their role through specialty certification from the Commission on Nurse Certification. As the American Association of Colleges of Nursing describes in the Competencies and Curricular Expectations for Clinical Nurse Leader Education and Practice, CNLs function in many roles.1 (See CNLs wear many hats.) CNLs provide a distinct perspective for the delivery of complex patient care by not only managing a patient case load but also analyzing and interpreting data for outcomes improvement, providing staff education and professional development, and creatively delegating and overseeing both human and fiscal resources. In collaboration with the interdisciplinary team, CNLs assess specific clinical microsystems to identify and implement evidence-based interventions that improve healthcare delivery and patient outcomes.2 (See What’s a clinical microsystem?) Indicators of improved patient outcomes may include decreased length of stay, improved patient safety, fewer inpatient admissions, and enhanced patient health knowledge.
52 l Nursing2014 l September
LAKOVK ALININ ANDL ORDR UNAR /iSTOCK
PATIENTS LIVING IN RURAL SETTINGS may find that many hospitals are in far-away urban areas. Patients are being discharged sooner than ever, many with complex health issues that need to be managed in outpatient settings, far beyond hospital walls. Empowering these patients to become the primary stakeholders of their own care in their own environment can enhance patient-centered care. Graduate-level clinical nurse leaders (CNLs) are RNs whose education has given them a solid foundation in nursing organization and policy, leadership, outcomes, and care management. This prepares CNLs to be effective change agents by helping nurses who work in rural areas increase patients’ access to healthcare. This article describes how CNLs can improve access to healthcare for patients living in rural areas along with the many nurses in various other roles who are already providing expert care.
www.Nursing2014.com
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
healthcare
www.Nursing2014.com
September l Nursing2014 l 53
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
In a rural setting, CNLs can decrease patients’ need for travel to a distant clinic or hospital, reduce the distress of travel, and decrease associated medical costs while enhancing the clinical services provided. Nurses already working in rural healthcare should consider getting the further education needed for this role. Increasing access A primary barrier for rural dwellers seeking healthcare is accessibility. As a CNL begins working with these patients, an initial focus is to increase access by bringing point-ofcare services to patients rather than expecting them to travel to a major healthcare center. Critical access hospitals (CAHs) are designated rural community hospitals receiving cost-based reimbursement from Medicare to facilitate services to areas where these services would otherwise be fiscally impossible.3 Many of these CAHs are limited in patient census and maximum length of stay, further increasing the need to reduce admissions and improve the overall health of the rural population.4 The CNL may be able to use some CAH resources, such as office space, computers, or telephones, as a base for reaching out to this underserved population. The CNL is likely to be an employee of the CAH itself rather than a rural clinic due to budget constraints and fiscal limitations. Improving patient education Health promotion and disease prevention education are vital to the well-being of patients in rural settings. Important topics for education include chronic disease management, prenatal care, reproductive health, alcohol and tobacco cessation, fall prevention, and medication safety. All rural nurses should identify patients with limited health literacy so that they can tailor patient education appropriately. Health illiteracy is associated with older age, low socioeconomic status, minority status, cultural or language barriers, and less than a high school education.5,6 54 l Nursing2014 l September
What’s a clinical microsystem? A clinical microsystem is a small group of patients and the professionals who regularly care for them.2 Often, these smaller groups are part of larger institutions or systems and are composed of people with similar needs.11 In a rural setting, clinical microsystems may be primary care clinics, remote hospitals, or even mobile healthcare teams. According to Nelson and colleagues, microsystems are living units that continuously evolve over time, yet always maintain a central focus on the patient.2 Microsystems are everywhere, at all levels of healthcare delivery, and may include family practice clinics, dialysis centers, home healthcare teams, and extended-care facilities.2
Those with limited health literacy may benefit from alternate methods of education; for example, telephone or videoconference sessions if available. (See Signs of low health literacy.) Try traveling clinics CNLs should also consider implementing small “traveling clinics” to provide information and perform some tasks that might otherwise require rural patients to travel long distances to healthcare centers or hospitals. Organized on a routine schedule, these traveling clinics journey to rural community centers, schools, churches, or other meeting places to bring specific services and health education to underserved patients. Nurses, including the CNL, can monitor vital signs, obtain blood specimens for routine lab work, perform wound care and other procedures, and administer immunizations. They may also teach patients to operate medical equipment such as home vital sign machines or telehealth scales and glucometers as well as provide other health education. Rural health nurses can also monitor and evaluate data collected during traveling clinic
CNLs wear many hats1 • • •
Clinician
• • • • • •
Educator
Outcomes manager Advocate for patients, staff, and communities Information manager Coordinator of patient care Risk anticipator Team manager Steward of resources.
visits, including attendance and type of intervention performed to ensure future improvements best serve the unique needs of the rural population.7 Tracking results, expanding scope Outcomes can best be measured through improved data points, such as decreased admissions, reduced length of stay, decreased readmissions, decreased fall rates, and increased home health referrals.4 These data should be tracked and analyzed at least quarterly to determine trends and variances in areas that require more intense focus. Using electronic medical record systems in rural healthcare settings significantly streamlines processes, easing the CNL’s workload and increasing efficiency. CNLs will need to perform assessments of the microsystem, including assessments of both patients and clinicians and of available resources. The CNL can assist amenable healthcare staff in the microsystem to develop specific competencies by providing or facilitating education to update their knowledge and skill set. As indicated by Strasser and Neusy, resource limitations in the rural setting include not only a lack of healthcare providers, but variable skill level of those who are present.8 Through the implementation of these interventions, CNLs assume the roles of patient advocate, clinician, educator, and outcomes manager. They anticipate risks to the overall health and wellness of the rural microsystem, overcoming barriers such as lack of insurance or limited financial means, transportation difficulties, www.Nursing2014.com
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
comorbidities, and insufficient preventive services. Unique challenges The success of these interventions will be largely based on the amount of community involvement. Collaboration with local healthcare providers and community leaders is key. Many formal and informal local leaders provide access to the trust of closely knit rural communities and suggest local meeting places that outsiders may miss. These essential advisors may assist in overcoming language barriers and function as culture brokers, helping CNLs to navigate complex family and community relationships. Interaction with these leaders may boost attendance at scheduled events and enhance patients’ willingness to participate in new services. Literature and announcements must be widely distributed using the Internet and various other resources. For example, radio and TV announcements can be effective, as can flyers posted at local gathering places such as churches, food stores, town halls, and post offices. Healthcare providers must recognize the cultural differences between urban and rural groups. Rural dwellers tend to be very resilient, have strong social networks, and be exceptionally self-reliant. Recognizing these particular characteristics as part of an ongoing assessment is imperative as they may actually increase the potential for certain disease states among rural inhabitants.4 Specifically, the Rural Health Research and Policy Centers reported that rural dwellers were more likely to experience poor health status, obesity, diabetes, and limitations in activity when compared with urban residents.9 Rural communities tend to have limited access to healthy living options such as gyms and a culture of high-fat dietary choices. Previous generations offset high-fat diets with physical labor that technology has, in many cases, made obsolete. Relative isolation from medical care combined with strong self-reliance www.Nursing2014.com
Signs of low health literacy12,13 Many patients who struggle with health literacy:
• •
miss scheduled visits.
•
create excuses to refrain from writing on documents during the appointment.
•
claim vision difficulties when reading in front of providers.
• •
ignore or misunderstand instructions.
ask to take forms home to complete them.
ask to sign paperwork with a thumbprint.
inhibits many from seeking preventive healthcare or early intervention.10 Patients in the rural clinical microsystem use a diverse array of technological resources. For tech-savvy patients with Internet access, encrypted e-mail and web-based education can greatly improve access to healthcare and adherence to treatment. Although they’re nearly ubiquitous in urban settings, smart phones or computers may not be as useful in rural areas due to network limitations or personal concerns, such as privacy, inability to afford service, and even technophobia. Many in rural areas rely instead on mail, telephone, and conversation among neighbors for information. For these patients, using telephone-moderated health assistive devices can maximize the rural healthcare experience. For instance, home placement of peripheral devices such as weight scales, sphygmomanometers, blood glucose monitors, and stethoscopes that are connected to telehealth equipment let nurses monitor clinical signs remotely. Even if they’re not up on the latest technology, most patients have access to a telephone, providing opportunities for follow-up and education. Visiting home health nurses can also improve outcomes by assessing patients in person, asking them to demonstrate personal care skills, and educating them about risk reduction, health promotion, and disease management.
Broad reach CNLs can utilize their education and skill sets to improve rural health through many routes. Patients who live far from hospitals in remote areas can only benefit from CNLs’ expertise and care. ■ REFERENCES 1. American Association of Colleges of Nursing. Competencies and Curricular Expectations for Clinical Nurse Leader Education and Practice. 2013. http:// www.aacn.nche.edu/cnl/CNL-CompetenciesOctober-2013.pdf. 2. Nelson EC, Batalden PB, Godfrey MM. Quality by Design: A Clinical Microsystems Approach. San Francisco, CA: Jossey-Bass/Wiley; 2007. 3. American Hospital Association. Critical Access Hospitals. 2013. http://www.aha.org/advocacyissues/cah/index.shtml. 4. Jukkala A, Greenwood R, Ladner K, Hopkins L. The clinical nurse leader and rural hospital safety and quality. Online J Rural Nurs Health Care. 2010;10(2):38-44. http://rnojournal.binghamton. edu/index.php/RNO/article/viewFile/45/45. 5. Berkman ND, Sheridan SL, Donahue KE, Halpern DJ, Crotty K. Low health literacy and health outcomes: an updated systematic review. Ann Intern Med. 2011;155(2):97-107. 6. Shipman JP, Kurtz-Rossi S, Funk CJ. The health information literacy research project. J Med Libr Assoc. 2009;97(4):293-301. 7. Tham R, Humphreys J, Kinsman L, et al. Evaluating the impact of sustainable comprehensive primary health care on rural health. Aust J Rural Health. 2010;18(4):166-172. 8. Strasser R, Neusy AJ. Context counts: training health workers in and for rural and remote areas. Bull World Health Organ. 2010;88(10):777-782. 9. Bennett KJ, Olatosi B, Probst JC. Health Disparities: A Rural-Urban Chartbook. Columbia, SC: South Carolina Rural Health Research Center; 2008. http://rhr.sph.sc.edu/report/(7-3)%20Health%20 Disparities%20A%20Rural%20Urban%20 Chartbook%20-%20Distribution%20Copy.pdf. 10. Befort CA, Nazir N, Perri MG. Prevalence of obesity among adults from rural and urban areas of the United States: findings from NHANES (2005-2008). J Rural Health. 2012;28(4):392-397. 11. Institute for Healthcare Improvement. Clinical Microsystem Assessment Tool. 2014. http://www.ihi.org/resources/pages/tools/ clinicalmicrosystemassessmenttool.aspx. 12. Agho AO, Deason LM, Rivers PA. Provider perceptions of health literacy in an urban community. Int J Health Promot Educ. 2011;49(2): 36-43. 13. Eggertson L. Health literacy: more than just the three Rs. Can Nurse. 2011;107(1):18-23. RESOURCE The Joint Commission. Health Care at the Crossroads: Guiding Principles for the Development of the Hospital of the Future. 2008. http://www. jointcommission.org/Guiding_Principles_for_The_ Development_of_the_Hospital_of_The_Future_. Tammy L. Rogers and Cheri R. Darden are nurse educators at Central Texas Veterans Healthcare System in Temple, Tex. The authors have disclosed that they have no financial relationships related to this article. DOI-10.1097/01.NURSE.0000452994.18665.57
September l Nursing2014 l 55
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
