ORIGINAL RESEARCH
The Southern states: NPs made an impact in rural and healthcare shortage areas Thomas Kippenbrock, EdD, RN (Professor)1 , Wen-Juo Lo, PhD (Associate Professor)1 , Ellen Odell, DNP, APRN (Director of Nursing)2 , & Bill Buron, PhD, APRN, FNP/GNP-BC (Assistant Dean for Nursing)3 1
University of Arkansas, Fayetteville, Arkansas John Brown University, Siloam Springs, Arkansas 3 University of Arkansas for Medical Sciences, Fayetteville, Arkansas 2
Keywords Nurse practitioners; primary care; research; rural. Correspondence Thomas Kippenbrock, EdD, RN, University of Arkansas, 606 Razorback Rd, Fayetteville, AR 72701. Tel: 479-575-5874; Fax: 479-575-3218; E-mail: [email protected] Received: 22 September 2014; accepted: 21 January 2015 doi: 10.1002/2327-6924.12245
Abstract Purpose: To investigate the distribution of nurse practitioners (NPs) in the U.S. Southern region with a focus on rural and underserved areas. Described in this study are the NP characteristics and their workforce distribution relative to rural and health professional shortage areas (HPSAs). Data sources: Method: A questionnaire was administered to NPs in 12 Southern states. Other data sources included (a) the Health Resources and Services Administration, which identified HPSAs; and (b) data from the U.S. Census Bureau, to distinguish urban and rural areas. Conclusions: Approximately 72% of NPs worked in HPSAs and less than half of the NPs worked in the rural area. Family NPs were more likely to practice in rural and HPSAs. Employment in primary care was more likely to occur in rural and HPSAs. Racial diversity was almost nonexistent within the NP population. Implication for practice: This research does demonstrate that NPs are practicing in rural and underserved areas as conceived decades ago, but there is still a great demand and gap to fill. To optimize their effectiveness, NPs need to practice to the full extent of their education. Additionally, more research and strategies to help diversify the workforce is needed.
Introduction The role of nurse practitioners (NPs) as healthcare providers was established in 1965 (Colorado University, 2014). The major academic program goal was to provide healthcare services to populations affected by a physician shortage and service misdistribution in rural settings. The role of this highly educated NP was focused on health promotion, disease prevention, and wellness (Zaccagnini & White, 2014). Nearly 50 years after the inception of the role, NPs enter the U.S. workforce at a current rate of 14,000 per year. The American Association of Nurse Practitioners (2014a) reported 192,000 NPs were currently practicing in the United States. However, despite national databases affiliated with the Bureau of Labor Statistics and the Health Resources and Services Administration (HRSA), knowledge is limited regarding the NP workforce in rural and medically underserved areas of the country. The aim of this research is to gain a better understanding of the characteristics of NPs working in the Southern United
Journal of the American Association of Nurse Practitioners 27 (2015) 707–713 C 2015 American Association of Nurse Practitioners
States. More specifically, the objectives are to examine and compare the demographic and descriptive characteristics (gender, race, income, practice specialty, and employer type) of NPs working in (a) health professional shortage areas (HPSAs) versus non-HPSA; and (b) rural versus urban areas.
Background From an historical perspective, the following states are known at the “Deep South”: Alabama (AL), Arkansas (AR), Florida (FL), Georgia (GA), Kentucky (KY), Louisiana (LA), Mississippi (MS), North Carolina (NC), South Carolina (SC), Tennessee (TN), Texas (TX), and Virginia (VA) (see Figure S1). A common perception of the Southern U.S. region is one of poverty, political corruption, large numbers of uneducated ignorant people, ill health, and disease (Cox, 2011). Genovese (1994) described the South as being “quintessentially conservative” (p. 1), implying a lack of reform or advancement. For 707
NP impact on the Southern states
T. Kippenbrock et al.
Table 1 Poverty, rural population, and selected health indicators: a comparison of 12 Southern states to national data
State National AL AR FL GA KY LA MS NC SC TN TX VA
Below poverty (%)/ highest state rankings*
Percentage of rural populations/ highest state rankings*
Life expectancies (years)/lowest state ranking*
American health rankings*
15.3 19.0/3 18.8/5 16.5 17.9/9 19.0/3 18.7/6 21.9/1 16.3 17.3 17.7 17.2/9 10.5
16 41/42 44/45 9 25 42/43 27 51/47 34 34 34 15 25
75.37 73.84/46 74.33/42 75.84 73.61/47 74.37/41 73.05/49 73.03/50 74.48/41 73.51/48 74.32/43 75.14 75.22
47th 49th 33rd 38th 45th 48th 50th 35th 43rd 42nd 36th 26th
Bold refers to state rankings.
reasons and forces outside the scope of this article, the South has been left behind in much of the nation’s progressive economic, social, and healthcare advances that launched the United States to global leadership. Even today, data demonstrate that these conditions have not substantially changed. Previous research has demonstrated an association between wealth inequality and poor population health (Nowatzki, 2012). There is also evidence that race, ethnicity, and language barriers create disparities in health care (Betancourt, Green, Carrillo, & Ananeh-Firempong, 2003; Fiscella, Franks, Doescher, & Saver, 2002). The South is plagued with numerous social and health problems. Table 1 provides information regarding the South’s poverty rates, percentage of population living in rural areas, and health status. The South has the some of the highest poverty rates in the nation. In the United States, poverty rates are calculated annually; the most recent data report that the national rate is 15.3% (U.S. Census Bureau, 2013a) and 11 of the 12 Southern states exceeded the national poverty line (Macartney & Mykyta, 2012). Furthermore, census data over the past decade demonstrated a statistically significant increase in the number of people in poverty aged 65 and older, people living in the South, and people living outside metropolitan areas (U.S. Census Bureau, 2013b). These compound the issues surrounding the health status of Southern populations. Health status can be measured by life expectancies. Death rates are calculated per 100,000 persons. In 2013, the average life expectancy for the United States was 75.37 years of age; the life expectancies of Southern citizens 708
were some of the lowest in the country (U.S. Census Bureau, 2013b; see Table 1). Finally, the American Health Rankings (United Health Foundation, 2013) evaluated the health of states based upon lifestyle, access to health care, occupational safety and disability, disease, and mortality rates. Again, Southern states did not fare well. Four Southern states earned the lowest health ranking with many other states in the lowest quartile as shown in Table 1. Lastly, data support the existence of healthcare disparities in rural populations. Compared with their urban counterparts, rural residents are more likely to be older, poorer, in fair or poor health, have more chronic conditions, and receive less recommended preventive services (U.S. Department of Health and Human Services, National Healthcare Disparities Report, 2014). Therefore, studying rural areas, especially the rural areas of the Southern region, is important in NP workforce analysis. The definition of a rural community is a municipality with a population of 100K 50K 50–99K >100K Employment length 0–5 years 6–10 years 11–15 years 16 and above
Non-HPSA N = 488
HPSA N = 1227
χ2
Urban N = 914
Rural N = 793
148 248
327 672
236 198
543 578
41 292 102
91 701 322
184 94 90 71
446 233 253 202
χ2 68.523**
2.720 173 547
301 366
342 477
435 294
57 513 247
76 477 172
323 165 189 154
304 158 156 116
49.502**
4.414*
12.002**
4.843
1.607
3.232
Note. *p < .05; **p < .01; HPSA, health professionals shortage area.
conducted. Also, with a larger sampling, all 50 states could be analyzed for their NP workforce.
Implications for workforce development The findings of this study continue to suggest that NPs are an important workforce in the delivery of primary care services to rural and underserved populations of the Southern region, an area of the country associated with poor economic and healthcare outcomes. NPs are working in the Southern states, are employed in HPSAs, and close to half work in the rural areas. This service is consistent with NP history and traditional educational frameworks, focused on providing healthcare services to rural and underserved populations. The United States continues to faces a serious shortage of primary care clinicians at a time when demands for healthcare services are scarce and expected to rise, particularly in rural and underserved areas. The National Center for Workforce Analysis (2013) projected a national primary care provider (PCP) shortage of 6400 FTE in 2020. Physicians remained the dominant PCP workforce but will decrease from an overall 77% of PCPs to 70% in 2020. The Center reported NPs as the second leading PCP (55,400) and predicted an increase to 72,000 in 2020. Compounding the national PCP shortage are the many regional shortages. The Association of American Medical Colleges (2013) reported that each of the Southern states were below the U.S. median of 90.3 primary care physicians per 100,000 population. In fact, Mississippi was the lowest in the country at 58.8 primary care physicians per 100,000 population. Because the Southern states have large rural areas, the study’s findings indicate that NPs are employed and practicing in the rural locations where they are most needed, thus reducing the PCP shortage. Almost three decades ago, the federal government issued a report about NPs being a suitable substitute for
physicians. Their conclusions were NPs provided similar healthcare services as primary care physicians at less cost but equal quality (U.S. Congress, Office of Technology Assessment, 1986). The same evidence holds true today. Martinez-Gonzalez et al. (2014) conducted a systematic review and meta-analysis of nurses being a substitution for primary care physicians. Nurse-led care, especially NPs, had a positive effect on patient satisfaction, reduced hospital admission, and lowered mortality. While NPs are a valuable asset to primary care services, unfortunately their ability to practice to the full extent of their educational preparation is often limited by unnecessary restrictions, including such barriers as equitable reimbursement and prescriptive authority. The NP needs to assess, diagnose, manage treatments, prescribe medication and therapies (including narcotics), and be reimbursed fairly. The need to lift such restrictions is highlighted by the Institute of Medicine (IOM) landmark 2010 Report, on the Future of Nursing: Leading Change, Advancing Health. The first recommendation in that report is to “remove scopeof-practice barriers” for APRNs (IOM, 2010). Exclusive licensure of authority needs to originate from the state boards of nursing with no interferences from medical boards. The American Association of Nurse Practitioners (2014b) identified each of the Southern states in this study as being reduced or restricted practice; thus none had full practice authority. This means the state practice and licensure laws restrict NPs in at least one of the elements described above. The law requires supervision, delegation, collaboration, or team management by physicians. Reduced and restrictive work environments are not in the best interest of patients and populations. This is especially true in rural and isolated counties where other PCPs are in critically short supply. Fortunately, more opportunities for NPs and the patients they serve are occurring with the passage of the federal 711
NP impact on the Southern states
law, the Patient Protection and Affordability Care Act. This law attempts to overhaul the healthcare system. In particular, one feature of the law is to increase private and public access to healthcare insurance. The Congressional Budget Office (2014) predicted that as a result of the Patient Protection and Affordability Care Act: (a) 24 or 25 million people will obtain health insurance each year through exchanges; (b) 12 or 13 million people will be added to the Medicaid and Children’s Health Insurance Program (CHIP) rolls; (c) 6 or 7 million fewer people will obtain insurance through their employer; and (d) 5 million fewer people will have nongroup or other coverage. Consequently, more people are likely to see an NP for their healthcare services. Compared to the length and cost of physician education, the mobilization of a new NP can occur more quickly at a relatively lower cost. In addition, NP education and practice typically builds on the expertise and experiences of seasoned registered nurses, who often represent a wide array of ethnic and cultural backgrounds. A renewed emphasis on educating more NPs to meet growing primary care demands would likely improve the diversity of healthcare providers. Furthermore, greater support for NP residencies (as encouraged in the IOM [2010] report) focused on rural and underserved areas may actually lead to improved care at a lower cost among these highly underserved and vulnerable populations.
References American Association of Nurse Practitioners. (2014a). NP fact sheets. Retrieved from http://www.aanp.org/all-about-nps/np-fact-sheet American Association of Nurse Practitioners. (2014b). State practice environments. Retrieved from http://www.aanp.org/legislation-regulation/state-legislationregulation/state-practice-environment American Hospital Association. (2013). Developing an effective health care workforce planning model. Retrieved from http://www.aha.org/content/13/13 wpmwhitepaperfinal.pdf Association of American Medical Colleges. (2013). 2013 State physician workforce data book. Retrieved from https://members.aamc.org/eweb/upload/State%20 Physician%20Workforce%20Data%20Book%202013%20%28PDF%29.pdf Betancourt, J., Green, A., Carrillo, J. E., & Ananeh-Firempong, O. (2003). Defining cultural competence: A practical framework for addressing racial/ethnic disparities in health and health care. Public Health Reports, 118, 293–302. Colorado University. (2014). Nursing history. Retrieved from http://www. ucdenver.edu/academics/colleges/nursing/about-us/history/Pages/ history.aspx Congressional Budget Office. (2014). Updated estimates of the insurance coverage provisions of the affordable care act. Retrieved from http://www.cbo.gov/ publication/45159 Cox, K. L. (2011). Dreaming of Dixie: How the south was created in American popular culture. Chapel Hill, NC: The University of North Carolina Press. DesRoches, C. M., Gaudet, J., Perloff, J., Donelan, K., Iezzoni, L. I., & Buerhaus, P. (2013). Using Medicare data to assess nurse practitioner-provided care. Nursing Outlook, 61(6), 400–407. doi:10.1016/j.outlook.2013.05.005
712
T. Kippenbrock et al.
Ennis, S. R., Rios-Vargus, M., & Albert, N. G. (2011). The Hispanic population: 2010. U.S. Census Bureau. Retrieved from http://www.census.gov/prod/ cen2010/briefs/c2010br-04.pdf Fiscella, K., Franks, P., Doescher, M., & Saver, B. (2002). Disparities in health care by race, ethnicity, and language among the insured: Findings from a national sample. Medical Care, 40(1), 52–59. Genovese, E. D. (1994). The southern tradition. Cambridge, MA: Harvard University Press. Gornick, M. E., Eggers, P. W., Reilly, T. W., Mentnech, R. M., Fitterman, L. K., Kucken, L. E., & Vladeck, B. C. (1996). Effects of race and income on mortality and use of services among Medicare beneficiaries. New England Journal of Medicine, 335(11), 791–799. Health and Human Services Administration. (2014). Shortage designation: Health professional shortage areas & medically underserved areas/populations. Retrieved from http://www.hrsa.gov/shortage/ Humos, K. R., Jones, M. A., & Ramirez, R. R. (2011). Overview of race and Hispanic origin: 2010. U.S. Census Bureau. Retrieved from http://www. census.gov/prod/cen2010/briefs/c2010br-02.pdf Institute of Medicine (IOM). (2010). The future of nursing: Leading change, advancing health. Retrieved from http://books.nap.edu/openbook.php? record˙id=12956&page=R1 Kippenbrock, T., Stacy A., Tester, K., & Richey, R. (2002). Nurse practitioners providing healthcare to rural and underserved areas in four Mississippi Delta states. Journal of Professional Nursing, 18(4), 230–237. Laveist, T., & Nuru-Jeter, A. (2002). Is doctor-patient concordance associated with greater satisfaction with care? Journal of Health and Social Behavior, 43(3), 296–306. Laviest, T., Nuru-Jeter, A., & Jones, K. (2003). The association of doctor-patient race concordance with health services utilization. Journal of Public Health Policy, 24(3/4), 312–323. Macartney, S., & Mykyta, L. (2012). Poverty and shared households by state: 2011. Retrieved from http://www.census.gov/hhes/www/poverty/publications/ acsbr11-05.html Martinez-Gonzalez, N. A., Djalali, S., Trandjung, R., Huber-Geismann, F., Markun, S., Wensing, M., & Rosemann, T. (2014). Substitution of physicians by nurses in primary care: A systematic review and meta-analysis. BMC Health Research Services, 12(214), 1–17. doi:10.1186/1472-6963-14-214 Moy, E., & Bartman, B. A. (1995). Physician race and care of minority and medically indigent patients. Journal of the American Medical Association, 17(273), 1515–1520. National Center for Workforce Analysis. (2013). Projecting the supply and demand for primary care practitioners through 2020. Health Resources and Services Administration Bureau of Health Profession. Rockville, MD: U.S. Department of Health and Human Services. Nowatzki, N. R. (2012). Wealth inequality and health: A political economy perspective. International Journal of Health Services, 42(3), 403–424. Odell, E., Kippenbrock, T., Buron, B., & Narcisse, M. R. (2013). Gaps in the primary care of rural and underserved populations: The impact of nurse practitioners in four Mississippi delta states. Journal of the American Academy of Nurse Practitioners. 25(12), 659–666. doi:10.1111/1745-7599. 12023 Rastogi, S., Johnson, T. D., Hoeffel, E. M., & Drewery, M. P. (2011). The black population: 2010. U.S. Census Bureau. Retrieved from http://www.census. gov/prod/cen2010/briefs/c2010br-06.pdf United Health Foundation. (2013). America’s health ranking 2013: A call to action for individuals and their communities. Minnetonka, MN: Author. Retrieved from http://www.americashealthrankings.org/rankings U.S. Census Bureau. (2013a). Poverty: Highlights. Retrieved from https://www. census.gov/hhes/www/poverty/about/overview/ U.S. Census Bureau. (2013b). The 2012 statistical abstract: The nation data book. Retrieved from http://www.census.gov/compendia/statab/ U.S. Congress, Office of Technology Assessment. (1986). Nurse practitioners, physician assistants, and certified nurse-midwives: A policy analysis. Washington, DC: U.S. Government Printing Office; Health Technology Case Study No. 37, Pub. No. OTA-HCS-37. R
NP impact on the Southern states
T. Kippenbrock et al.
U.S. Department of Health and Human Services, Agency for Healthcare Research and Quality. (2014). National healthcare disparities report (AHRQ Publication No. 14–0006). Retrieved from http://www.ahrq.gov/research/ findings/nhqrdr/nhdr13/2013nhdr.pdf World Health Organization (WHO). (1978). Declaration of Alma-Ata. International Conference on Primary Health Care, Alma-Ata, USSR, 6–12. Retrieved from http://www.euro.who.int/en/publications/policydocuments/declaration-of-alma-ata,-1978
Zaccagnini, M. E., & White, K. W. (2014). The doctor of nursing practice essentials: A new model for advanced practice nursing (2nd ed.). Burlington, MA: Jones & Bartlett Learning.
Supporting Information Additional supporting information may be found in the online version of this article at the publisher’s web-site.
713
The Southern states: NPs made an impact in rural and healthcare shortage areas Thomas Kippenbrock, EdD, RN (Professor)1 , Wen-Juo Lo, PhD (Associate Professor)1 , Ellen Odell, DNP, APRN (Director of Nursing)2 , & Bill Buron, PhD, APRN, FNP/GNP-BC (Assistant Dean for Nursing)3 1
University of Arkansas, Fayetteville, Arkansas John Brown University, Siloam Springs, Arkansas 3 University of Arkansas for Medical Sciences, Fayetteville, Arkansas 2
Keywords Nurse practitioners; primary care; research; rural. Correspondence Thomas Kippenbrock, EdD, RN, University of Arkansas, 606 Razorback Rd, Fayetteville, AR 72701. Tel: 479-575-5874; Fax: 479-575-3218; E-mail: [email protected] Received: 22 September 2014; accepted: 21 January 2015 doi: 10.1002/2327-6924.12245
Abstract Purpose: To investigate the distribution of nurse practitioners (NPs) in the U.S. Southern region with a focus on rural and underserved areas. Described in this study are the NP characteristics and their workforce distribution relative to rural and health professional shortage areas (HPSAs). Data sources: Method: A questionnaire was administered to NPs in 12 Southern states. Other data sources included (a) the Health Resources and Services Administration, which identified HPSAs; and (b) data from the U.S. Census Bureau, to distinguish urban and rural areas. Conclusions: Approximately 72% of NPs worked in HPSAs and less than half of the NPs worked in the rural area. Family NPs were more likely to practice in rural and HPSAs. Employment in primary care was more likely to occur in rural and HPSAs. Racial diversity was almost nonexistent within the NP population. Implication for practice: This research does demonstrate that NPs are practicing in rural and underserved areas as conceived decades ago, but there is still a great demand and gap to fill. To optimize their effectiveness, NPs need to practice to the full extent of their education. Additionally, more research and strategies to help diversify the workforce is needed.
Introduction The role of nurse practitioners (NPs) as healthcare providers was established in 1965 (Colorado University, 2014). The major academic program goal was to provide healthcare services to populations affected by a physician shortage and service misdistribution in rural settings. The role of this highly educated NP was focused on health promotion, disease prevention, and wellness (Zaccagnini & White, 2014). Nearly 50 years after the inception of the role, NPs enter the U.S. workforce at a current rate of 14,000 per year. The American Association of Nurse Practitioners (2014a) reported 192,000 NPs were currently practicing in the United States. However, despite national databases affiliated with the Bureau of Labor Statistics and the Health Resources and Services Administration (HRSA), knowledge is limited regarding the NP workforce in rural and medically underserved areas of the country. The aim of this research is to gain a better understanding of the characteristics of NPs working in the Southern United
Journal of the American Association of Nurse Practitioners 27 (2015) 707–713 C 2015 American Association of Nurse Practitioners
States. More specifically, the objectives are to examine and compare the demographic and descriptive characteristics (gender, race, income, practice specialty, and employer type) of NPs working in (a) health professional shortage areas (HPSAs) versus non-HPSA; and (b) rural versus urban areas.
Background From an historical perspective, the following states are known at the “Deep South”: Alabama (AL), Arkansas (AR), Florida (FL), Georgia (GA), Kentucky (KY), Louisiana (LA), Mississippi (MS), North Carolina (NC), South Carolina (SC), Tennessee (TN), Texas (TX), and Virginia (VA) (see Figure S1). A common perception of the Southern U.S. region is one of poverty, political corruption, large numbers of uneducated ignorant people, ill health, and disease (Cox, 2011). Genovese (1994) described the South as being “quintessentially conservative” (p. 1), implying a lack of reform or advancement. For 707
NP impact on the Southern states
T. Kippenbrock et al.
Table 1 Poverty, rural population, and selected health indicators: a comparison of 12 Southern states to national data
State National AL AR FL GA KY LA MS NC SC TN TX VA
Below poverty (%)/ highest state rankings*
Percentage of rural populations/ highest state rankings*
Life expectancies (years)/lowest state ranking*
American health rankings*
15.3 19.0/3 18.8/5 16.5 17.9/9 19.0/3 18.7/6 21.9/1 16.3 17.3 17.7 17.2/9 10.5
16 41/42 44/45 9 25 42/43 27 51/47 34 34 34 15 25
75.37 73.84/46 74.33/42 75.84 73.61/47 74.37/41 73.05/49 73.03/50 74.48/41 73.51/48 74.32/43 75.14 75.22
47th 49th 33rd 38th 45th 48th 50th 35th 43rd 42nd 36th 26th
Bold refers to state rankings.
reasons and forces outside the scope of this article, the South has been left behind in much of the nation’s progressive economic, social, and healthcare advances that launched the United States to global leadership. Even today, data demonstrate that these conditions have not substantially changed. Previous research has demonstrated an association between wealth inequality and poor population health (Nowatzki, 2012). There is also evidence that race, ethnicity, and language barriers create disparities in health care (Betancourt, Green, Carrillo, & Ananeh-Firempong, 2003; Fiscella, Franks, Doescher, & Saver, 2002). The South is plagued with numerous social and health problems. Table 1 provides information regarding the South’s poverty rates, percentage of population living in rural areas, and health status. The South has the some of the highest poverty rates in the nation. In the United States, poverty rates are calculated annually; the most recent data report that the national rate is 15.3% (U.S. Census Bureau, 2013a) and 11 of the 12 Southern states exceeded the national poverty line (Macartney & Mykyta, 2012). Furthermore, census data over the past decade demonstrated a statistically significant increase in the number of people in poverty aged 65 and older, people living in the South, and people living outside metropolitan areas (U.S. Census Bureau, 2013b). These compound the issues surrounding the health status of Southern populations. Health status can be measured by life expectancies. Death rates are calculated per 100,000 persons. In 2013, the average life expectancy for the United States was 75.37 years of age; the life expectancies of Southern citizens 708
were some of the lowest in the country (U.S. Census Bureau, 2013b; see Table 1). Finally, the American Health Rankings (United Health Foundation, 2013) evaluated the health of states based upon lifestyle, access to health care, occupational safety and disability, disease, and mortality rates. Again, Southern states did not fare well. Four Southern states earned the lowest health ranking with many other states in the lowest quartile as shown in Table 1. Lastly, data support the existence of healthcare disparities in rural populations. Compared with their urban counterparts, rural residents are more likely to be older, poorer, in fair or poor health, have more chronic conditions, and receive less recommended preventive services (U.S. Department of Health and Human Services, National Healthcare Disparities Report, 2014). Therefore, studying rural areas, especially the rural areas of the Southern region, is important in NP workforce analysis. The definition of a rural community is a municipality with a population of 100K 50K 50–99K >100K Employment length 0–5 years 6–10 years 11–15 years 16 and above
Non-HPSA N = 488
HPSA N = 1227
χ2
Urban N = 914
Rural N = 793
148 248
327 672
236 198
543 578
41 292 102
91 701 322
184 94 90 71
446 233 253 202
χ2 68.523**
2.720 173 547
301 366
342 477
435 294
57 513 247
76 477 172
323 165 189 154
304 158 156 116
49.502**
4.414*
12.002**
4.843
1.607
3.232
Note. *p < .05; **p < .01; HPSA, health professionals shortage area.
conducted. Also, with a larger sampling, all 50 states could be analyzed for their NP workforce.
Implications for workforce development The findings of this study continue to suggest that NPs are an important workforce in the delivery of primary care services to rural and underserved populations of the Southern region, an area of the country associated with poor economic and healthcare outcomes. NPs are working in the Southern states, are employed in HPSAs, and close to half work in the rural areas. This service is consistent with NP history and traditional educational frameworks, focused on providing healthcare services to rural and underserved populations. The United States continues to faces a serious shortage of primary care clinicians at a time when demands for healthcare services are scarce and expected to rise, particularly in rural and underserved areas. The National Center for Workforce Analysis (2013) projected a national primary care provider (PCP) shortage of 6400 FTE in 2020. Physicians remained the dominant PCP workforce but will decrease from an overall 77% of PCPs to 70% in 2020. The Center reported NPs as the second leading PCP (55,400) and predicted an increase to 72,000 in 2020. Compounding the national PCP shortage are the many regional shortages. The Association of American Medical Colleges (2013) reported that each of the Southern states were below the U.S. median of 90.3 primary care physicians per 100,000 population. In fact, Mississippi was the lowest in the country at 58.8 primary care physicians per 100,000 population. Because the Southern states have large rural areas, the study’s findings indicate that NPs are employed and practicing in the rural locations where they are most needed, thus reducing the PCP shortage. Almost three decades ago, the federal government issued a report about NPs being a suitable substitute for
physicians. Their conclusions were NPs provided similar healthcare services as primary care physicians at less cost but equal quality (U.S. Congress, Office of Technology Assessment, 1986). The same evidence holds true today. Martinez-Gonzalez et al. (2014) conducted a systematic review and meta-analysis of nurses being a substitution for primary care physicians. Nurse-led care, especially NPs, had a positive effect on patient satisfaction, reduced hospital admission, and lowered mortality. While NPs are a valuable asset to primary care services, unfortunately their ability to practice to the full extent of their educational preparation is often limited by unnecessary restrictions, including such barriers as equitable reimbursement and prescriptive authority. The NP needs to assess, diagnose, manage treatments, prescribe medication and therapies (including narcotics), and be reimbursed fairly. The need to lift such restrictions is highlighted by the Institute of Medicine (IOM) landmark 2010 Report, on the Future of Nursing: Leading Change, Advancing Health. The first recommendation in that report is to “remove scopeof-practice barriers” for APRNs (IOM, 2010). Exclusive licensure of authority needs to originate from the state boards of nursing with no interferences from medical boards. The American Association of Nurse Practitioners (2014b) identified each of the Southern states in this study as being reduced or restricted practice; thus none had full practice authority. This means the state practice and licensure laws restrict NPs in at least one of the elements described above. The law requires supervision, delegation, collaboration, or team management by physicians. Reduced and restrictive work environments are not in the best interest of patients and populations. This is especially true in rural and isolated counties where other PCPs are in critically short supply. Fortunately, more opportunities for NPs and the patients they serve are occurring with the passage of the federal 711
NP impact on the Southern states
law, the Patient Protection and Affordability Care Act. This law attempts to overhaul the healthcare system. In particular, one feature of the law is to increase private and public access to healthcare insurance. The Congressional Budget Office (2014) predicted that as a result of the Patient Protection and Affordability Care Act: (a) 24 or 25 million people will obtain health insurance each year through exchanges; (b) 12 or 13 million people will be added to the Medicaid and Children’s Health Insurance Program (CHIP) rolls; (c) 6 or 7 million fewer people will obtain insurance through their employer; and (d) 5 million fewer people will have nongroup or other coverage. Consequently, more people are likely to see an NP for their healthcare services. Compared to the length and cost of physician education, the mobilization of a new NP can occur more quickly at a relatively lower cost. In addition, NP education and practice typically builds on the expertise and experiences of seasoned registered nurses, who often represent a wide array of ethnic and cultural backgrounds. A renewed emphasis on educating more NPs to meet growing primary care demands would likely improve the diversity of healthcare providers. Furthermore, greater support for NP residencies (as encouraged in the IOM [2010] report) focused on rural and underserved areas may actually lead to improved care at a lower cost among these highly underserved and vulnerable populations.
References American Association of Nurse Practitioners. (2014a). NP fact sheets. Retrieved from http://www.aanp.org/all-about-nps/np-fact-sheet American Association of Nurse Practitioners. (2014b). State practice environments. Retrieved from http://www.aanp.org/legislation-regulation/state-legislationregulation/state-practice-environment American Hospital Association. (2013). Developing an effective health care workforce planning model. Retrieved from http://www.aha.org/content/13/13 wpmwhitepaperfinal.pdf Association of American Medical Colleges. (2013). 2013 State physician workforce data book. Retrieved from https://members.aamc.org/eweb/upload/State%20 Physician%20Workforce%20Data%20Book%202013%20%28PDF%29.pdf Betancourt, J., Green, A., Carrillo, J. E., & Ananeh-Firempong, O. (2003). Defining cultural competence: A practical framework for addressing racial/ethnic disparities in health and health care. Public Health Reports, 118, 293–302. Colorado University. (2014). Nursing history. Retrieved from http://www. ucdenver.edu/academics/colleges/nursing/about-us/history/Pages/ history.aspx Congressional Budget Office. (2014). Updated estimates of the insurance coverage provisions of the affordable care act. Retrieved from http://www.cbo.gov/ publication/45159 Cox, K. L. (2011). Dreaming of Dixie: How the south was created in American popular culture. Chapel Hill, NC: The University of North Carolina Press. DesRoches, C. M., Gaudet, J., Perloff, J., Donelan, K., Iezzoni, L. I., & Buerhaus, P. (2013). Using Medicare data to assess nurse practitioner-provided care. Nursing Outlook, 61(6), 400–407. doi:10.1016/j.outlook.2013.05.005
712
T. Kippenbrock et al.
Ennis, S. R., Rios-Vargus, M., & Albert, N. G. (2011). The Hispanic population: 2010. U.S. Census Bureau. Retrieved from http://www.census.gov/prod/ cen2010/briefs/c2010br-04.pdf Fiscella, K., Franks, P., Doescher, M., & Saver, B. (2002). Disparities in health care by race, ethnicity, and language among the insured: Findings from a national sample. Medical Care, 40(1), 52–59. Genovese, E. D. (1994). The southern tradition. Cambridge, MA: Harvard University Press. Gornick, M. E., Eggers, P. W., Reilly, T. W., Mentnech, R. M., Fitterman, L. K., Kucken, L. E., & Vladeck, B. C. (1996). Effects of race and income on mortality and use of services among Medicare beneficiaries. New England Journal of Medicine, 335(11), 791–799. Health and Human Services Administration. (2014). Shortage designation: Health professional shortage areas & medically underserved areas/populations. Retrieved from http://www.hrsa.gov/shortage/ Humos, K. R., Jones, M. A., & Ramirez, R. R. (2011). Overview of race and Hispanic origin: 2010. U.S. Census Bureau. Retrieved from http://www. census.gov/prod/cen2010/briefs/c2010br-02.pdf Institute of Medicine (IOM). (2010). The future of nursing: Leading change, advancing health. Retrieved from http://books.nap.edu/openbook.php? record˙id=12956&page=R1 Kippenbrock, T., Stacy A., Tester, K., & Richey, R. (2002). Nurse practitioners providing healthcare to rural and underserved areas in four Mississippi Delta states. Journal of Professional Nursing, 18(4), 230–237. Laveist, T., & Nuru-Jeter, A. (2002). Is doctor-patient concordance associated with greater satisfaction with care? Journal of Health and Social Behavior, 43(3), 296–306. Laviest, T., Nuru-Jeter, A., & Jones, K. (2003). The association of doctor-patient race concordance with health services utilization. Journal of Public Health Policy, 24(3/4), 312–323. Macartney, S., & Mykyta, L. (2012). Poverty and shared households by state: 2011. Retrieved from http://www.census.gov/hhes/www/poverty/publications/ acsbr11-05.html Martinez-Gonzalez, N. A., Djalali, S., Trandjung, R., Huber-Geismann, F., Markun, S., Wensing, M., & Rosemann, T. (2014). Substitution of physicians by nurses in primary care: A systematic review and meta-analysis. BMC Health Research Services, 12(214), 1–17. doi:10.1186/1472-6963-14-214 Moy, E., & Bartman, B. A. (1995). Physician race and care of minority and medically indigent patients. Journal of the American Medical Association, 17(273), 1515–1520. National Center for Workforce Analysis. (2013). Projecting the supply and demand for primary care practitioners through 2020. Health Resources and Services Administration Bureau of Health Profession. Rockville, MD: U.S. Department of Health and Human Services. Nowatzki, N. R. (2012). Wealth inequality and health: A political economy perspective. International Journal of Health Services, 42(3), 403–424. Odell, E., Kippenbrock, T., Buron, B., & Narcisse, M. R. (2013). Gaps in the primary care of rural and underserved populations: The impact of nurse practitioners in four Mississippi delta states. Journal of the American Academy of Nurse Practitioners. 25(12), 659–666. doi:10.1111/1745-7599. 12023 Rastogi, S., Johnson, T. D., Hoeffel, E. M., & Drewery, M. P. (2011). The black population: 2010. U.S. Census Bureau. Retrieved from http://www.census. gov/prod/cen2010/briefs/c2010br-06.pdf United Health Foundation. (2013). America’s health ranking 2013: A call to action for individuals and their communities. Minnetonka, MN: Author. Retrieved from http://www.americashealthrankings.org/rankings U.S. Census Bureau. (2013a). Poverty: Highlights. Retrieved from https://www. census.gov/hhes/www/poverty/about/overview/ U.S. Census Bureau. (2013b). The 2012 statistical abstract: The nation data book. Retrieved from http://www.census.gov/compendia/statab/ U.S. Congress, Office of Technology Assessment. (1986). Nurse practitioners, physician assistants, and certified nurse-midwives: A policy analysis. Washington, DC: U.S. Government Printing Office; Health Technology Case Study No. 37, Pub. No. OTA-HCS-37. R
NP impact on the Southern states
T. Kippenbrock et al.
U.S. Department of Health and Human Services, Agency for Healthcare Research and Quality. (2014). National healthcare disparities report (AHRQ Publication No. 14–0006). Retrieved from http://www.ahrq.gov/research/ findings/nhqrdr/nhdr13/2013nhdr.pdf World Health Organization (WHO). (1978). Declaration of Alma-Ata. International Conference on Primary Health Care, Alma-Ata, USSR, 6–12. Retrieved from http://www.euro.who.int/en/publications/policydocuments/declaration-of-alma-ata,-1978
Zaccagnini, M. E., & White, K. W. (2014). The doctor of nursing practice essentials: A new model for advanced practice nursing (2nd ed.). Burlington, MA: Jones & Bartlett Learning.
Supporting Information Additional supporting information may be found in the online version of this article at the publisher’s web-site.
713
