Addressing the Nursing Shortage:
Impacts and Innovations in Frontier America
December 2004

Frontier Education Center
NATIONAL CLEARINGHOUSE FOR FRONTIER COMMUNITIES
In partnership with the Health Resources and Service Administration's Office of Rural Health Policy, U. S. Department of Health and Human Services

For Document Text: PDF (469k) file

For Appendix A and Appendix B (138k)

For Appendix C: Maps
Nursing Shortage All 48 (448k)
Nursing Shortage Frontier 48 (661k)
Nursing Shortage All 50 (359k)
Nursing Shortage Frontier 50 (583k)






ADDRESSING THE NURSING SHORTAGE:
IMPACTS AND INNOVATIONS IN FRONTIER AMERICA

I.	Introduction
II.	Background
III.	Impact of the Nursing Shortgage in the Frontier
IV.	Nursing in Frontier and Rural Communities
V.	Strategies for increasing the supply and retention of Rural/Frontier Nurses
VI.	Summary and Conclusion

I. INTRODUCTION

The national nursing shortage is well chronicled in studies and articles ranging from such diverse sources as the Bureau of Health Professions to monthly magazines such as Reader's Digest. The Frontier Education Center seeks to assess how small communities are addressing nursing shortages and are continuing to provide nursing and home health care.

Frontier communities are the most sparsely populated and isolated areas of the United States . They experience many of the same problems as more densely populated areas, but experience even more obstacles due to isolation, distance from facilities and services, and lack of community resources.

This paper will discuss how the nursing shortage affects rural and frontier communities, highlighting the challenges that are specific to rural and frontier communities, and strategies developed at different levels - regional, state, and local - to increase the supply of nurses who practice in these communities. Strategies to address the nursing shortage are highlighted in boxes; the intent is not to present a comprehensive list or suggest "best practice" but to recognize creativity and the broad range of opportunities that may exist for these communities to ensure access to essential nursing care.

II. BACKGROUND

A National And International Shortage

The American Nurses Association (ANA) reports that that the nursing shortage will have an impact on health care delivery throughout the nation. Although the country has experienced shortages in the past, it is believed that this burgeoning nursing shortage is unlike any other, due to increasing health care demands of an aging American population and changes in the nursing profession. Moreover, the shortage extends beyond the U.S.; many experts call it an international shortage, in which competition between countries for available nurses may be expected to raise numerous debates of equity and fairness as wealthier countries draw educated health providers from poorer countries who can ill-afford to lose them.

While some areas currently suffer from the shortage, it is expected to continue to worsen throughout the next two decades. In 2000, there were 30 states that were estimated to have shortages of registered nurses; by 2020, 44 states and the District of Columbia are projected to have shortages (U.S. Department of Health and Human Services 2002a).

The Bureau of Labor Statistics has estimated that there will be more than one million openings for registered nurses between 2002 and 2012, with registered nurses ranking first in occupations with the largest growth (Hecker 2004). And, a recent analysis by the Bureau of Health Professions estimates that the supply of nurses will fall 29 percent below requirements by the year 2020, unless dramatic interventions and significant investments are developed and implemented (U.S. Department of Health and Human Services 2002a).

Factors Contributing To The Nursing Shortage

The causes of the nursing shortage have been the subject of numerous studies and analyses. While some pose the shortage as primarily a "supply" issue, the Bureau of Health Professions analysis, Projected Supply, Demand, and Shortages of Registered Nurses: 2000-2020 (U.S. Department of Health and Human Services 2002a), also highlights the forces behind increase in demand for registered nurses. These include two major demographic factors: the overall growth of the U.S. population that has outpaced the growth of registered nurses; and the aging of the population, resulting in an increased need for health care.

Supply (Drivers and Trends) Declining numbers of nursing graduates Aging of the RN workforce Declines in relative earnings

Demand (Drivers and Trends) Population growth and aging Trends in health care financing

Similarly, the American Association of Colleges of Nursing identifies the following key factors:

	A shortage of nursing school faculty is restricting nursing program enrollments;
	With fewer new nurses entering the profession, the average age of the RN is climbing;
	The total population of registered nurses is growing at the slowest rate in 20 years;
	Changing demographics signal a need for more nurses to care for an aging population; and,
	Job burnout and dissatisfaction are driving nurses to leave the profession (American Association of Colleges of Nursing 2004).

A shortage of nursing faculty appears to be a key bottleneck in the supply of nurses, as many nursing schools have experienced an increase in the number of applicants that they are unable to accept. The aging of nursing faculty reflects a number of dissatisfactions with academic nursing, including a gulf between academic research and applied practice, the "publish or perish" demands of academia, and the fact that practicing BSNs can easily earn as much or more than nursing faculty who must undergo many more years of schooling.

The Nurse Reinvestment Act

With the strong support of major health care organizations, the House and Senate passed a bill in July 2002 designed to increase recruitment and retention of nurses by making nursing a more rewarding and inviting profession. The act was written to encourage men and women to enter the nursing profession, to offer continuing education and more chances of advancement, and to increase the number of nursing school faculty. In August 2002, President Bush signed the Nurse Reinvestment Act into law (PL 107-205), and in February 2003, both chambers of Congress passed the FY 2003 Omnibus Appropriations bill, enacting and funding the Nurse Reinvestment Act programs.

The Nurse Reinvestment Act will:

	Create nurse retention and patient safety improvement grants;
	Offer scholarships for nursing students through the National Nurse Service Corps;
	Provide for a public service announcement campaign to promote nursing as a profession;
	Offer grants to nursing schools for faculty loan programs;
	Create career ladder programs;
	Establish comprehensive geriatric training grants for nurses (PL 107-205).

III. IMPACT OF THE NURSING SHORTAGE IN THE FRONTIER

Available data and literature suggest that the impact of the nursing shortage on rural and frontier communities varies greatly from community to community. While some rural/frontier communities face lengthy vacancy and recruitment time frames, others have no difficulty filling vacancies. In many frontier and rural communities, nursing jobs pay relatively well by community standards, so there may be high demand for few jobs. However, in other areas, recruiting for openings in rural areas is estimated to take about 60 percent longer to fill than in urban areas (Long 2000). Nurse employers may receive many applications but often find applicants do not meet desired qualifications; they often have to accept lower qualifications to fill positions.

The nursing shortage has exacerbated an already difficult task of recruiting rural nurses by driving up wages for nurses. Rural employers cannot compete with urban employers in terms of wages/bonuses offered to recruit BSNs and MSNs. Non-hospital care settings fare the worst, as private practices, schools, nursing homes and home care providers typically pay less than hospitals (Jacob 2001; National Association for Home Care 2003).

Using data from the 2000 National Sample Survey of Registered Nurses (NSSRN)
(U.S. Department of Health and Human Services, no date), respondents were aggregated by county type (where county type refers to place of employment) to compare frontier and non-frontier nurses on a number of indicators: percent of respondents who live and work in the same county; race/ethnicity; type of degree program for RN certification (basic nursing education); highest degree received; employment status; and income earned (see tables 1 and 2 in Appendix A).

Table 1 shows a comparison of county of residence and county of employment, revealing that frontier respondents were more likely to live and work in the same county (85%) than non-frontier respondents (75%), likely a reflection of the smaller county area of non-frontier counties and a greater likelihood of crossing county boundaries while traveling to routine activity destinations.

Differences in education between frontier and non-frontier nurses were also evident, both in their basic nursing education and the highest degree earned. Fully half of frontier nurses had qualified as RNs through associate degree (ADN) programs, in comparison with 40% of the non-frontier nurses; in contrast, non-frontier nurses were more likely to have attended diploma or BSN programs. Differences remained when looking at highest degree received; 44% of frontier nurses' highest degree was the ADN, in contrast with 34% of the non-frontier nurses. And, while the percentage of nurses who had earned a bachelors degree was slightly lower among frontier nurses (30% frontier, 33% non-frontier), the percentage who had earned masters degrees was also lower among frontier (7% frontier compared with 10% non-frontier).

Salary data are shown in Appendix A, Table 2 for all respondents employed in nursing at the time of the survey, for respondents employed full-time in nursing, and for respondents whose highest degree was a BSN employed in full-time nursing. For all three variables, respondents employed in frontier counties had a higher proportion than non-frontier respondents in income categories below $75,000 per year, and a lower proportion in income categories over $75,000 per year.



Although the impact of the shortage may not be evenly felt across rural and frontier communities, many experts perceive the shortage to disproportionately affect frontier and rural communities (Trossman 2001). As reported in the Boulder, Colorado Daily Camera, it's very difficult for rural areas to compete against large urban hospitals with the resources to entice the dwindling supply of registered nurses (Long 2000). At Prairie Vista Nursing Home in Holyoke, Colorado, a town of about 1,900 people about 130 miles northeast of Denver, administrators reportedly had to work double shifts to cover shifts after a nurse retired.

Quantifying The Nurse Shortage: Hospital-Based Nurse Shortage Counties

To what extent is the nursing shortage felt in frontier communities? It is difficult to quantitatively assess the impact of the nursing shortage in frontier areas because little frontier-specific data on the nursing shortage is available. However, where county-level data is available, it is possible to make comparisons of frontier counties to non-frontier counties using the 2000 Census data and applying the Consensus Definition (Frontier Education Center 2000a; 2000b).

The Bureau of Health Professions has classified Nurse Shortage Counties based on a ratio of the number of hospital-based nurse FTEs over the adjusted daily census and aggregated to the county level (Bureau of Health Professions, no date). Ratios were calculated using data from the 1999 American Hospital Association Annual Survey (Jordan 2004). The 1999 American Hospital Association Annual Survey does not record any hospital for 633 of the 3,141 counties (Cecil B. Sheps Center for Health Services Research 2004); no ratios could be calculated for these counties and thus were not classified as shortage counties. Of the 3,141 counties and administrative equivalents defined at the 2000 Census, a total of 880 (28%) were classified as nurse shortage counties; among the 2,058 counties with hospitals, 35% were classified as nurse shortage counties.



Using this list, frontier counties were classified as nurse shortage or non-shortage frontier counties (see Appendix B). Of 811 frontier counties, 557 had hospitals and 287 were classified as nurse shortage counties (52%), in contrast with 593 of 1,951 non-frontier counties (30%). Maps showing the frontier counties and their nurse shortage designations illustrate not only the widespread nature of the problem, but also how shortage counties and counties without any hospital are frequently clustered (Appendix C).



The appropriateness of hospital-based nurse shortage indicators for frontier counties may be questioned. First, proportionately more frontier counties did not have a hospital in 1999, and thus were not assessed as nurse shortage counties⁽³⁾ . Among frontier counties, 31% lacked hospitals, nearly double the percentage of non-frontier counties without hospitals (16%).



Among counties that do have hospitals, a very low average daily census is the norm⁽³⁾. This means that one or two nurses may appear "adequate," when in reality access to nursing care is limited. One characteristic of this 'small numbers problem' is that even in communities where nurse staffing is adequate, a single nurse may be the difference between adequate and underserved; a rural or frontier community is "always one nurse away" from a shortage (Trossman 2001).

Moreover, a single hospital may serve the entire county. As frontier counties tend to be much larger than non-frontier counties, the geographic area served by the hospital is much larger. The burden of distance to care and the inability of small frontier and rural communities to take advantage of efficiencies of scale suggest that a higher per capita level of staffing is required in frontier communities to provide the same level of access to care as in more populous communities. Finally, skilled nursing care in non-hospital settings - such as home health, public health, primary care, school health - is more frequent for frontier and rural populations than hospital-based care.

Thus, relative to non-frontier counties, this nurse shortage indicator may underestimate the shortage for frontier counties. For example, in New Mexico (a largely frontier state), San Miguel County is the only county designated as a nurse shortage county, a result that runs counter to local expert perceptions. Indeed, eight counties in New Mexico did not have any hospital in 1999, and at the state level using nurses-per-capita as an indicator, New Mexico (#42) ranks in the bottom ten states (California, Utah, Texas, Arizona, Oklahoma, Idaho, New Mexico, Georgia, and Arkansas) (Jacob 2001).

Non-Hospital Nursing Shortages

School nurse shortage. The National Association of Elementary School Principals (NAESP) advocates for a full-time nurse in every school; on that basis, the NAESP estimates a need for 91,000 school nurses, while only 57,954 RNs were employed as school nurses (Magnuson 2002). In addition to the declining supply of nurses and increasing competition, state budgets for education have been declining to a crisis point in many states. School nurse positions are cut as a result. Rural and frontier communities, with lower tax bases to begin with, are the most vulnerable.

Even where school nurse positions are budgeted, the shortage makes it difficult for school districts to recruit nurses. In New Mexico, the Espanola school district had seven nurses to share among 15 schools (Green 2004). The superintendent attributed the lack of nurses for some schools to the nurse shortage; positions were budgeted and advertised, but no one applied. According to the National Association of School Nurses, "the No Child Left Behind Act allows local uses of funds for programs to hire and support school nurses under "Title V, Innovative Program," although many other programs and services compete for these funds" (National Association of School Nurses 2004).

Home health and the nurse shortage. The past decade has witnessed the ongoing restructuring of the health care industry, and a number of important policy shifts have responded and added to these changes. Home health care has seen a simultaneous increase in demand and decline in reimbursement, resulting in a highly unstable industry. The closure of a large number of home health agencies has been the subject of scrutiny and controversy. At the aggregate (national) level, these closures represent consolidation and do not appear to have reduced access to home health services; closures of home health agencies located within rural counties are compensated by urban agencies providing services to rural residents (MedPac 2001; Franco 2004).

The National Association for Home Care and Hospice maintains that rural home health agencies experience lower margins and are therefore more vulnerable to closures than urban agencies; these lower margins would also discourage urban providers from providing services in rural areas. Travel time, low patient census, and lack of community support structures raise the costs of providing home care in rural areas (National Association for Home Care and Hospice 2003). The 2001 MedPac report, for example, confirms that home health agencies are less willing to accept certain higher cost patients, including some rural patients. And, because analysis at the aggregate level masks variation at regional, state, and local levels, the problem may be more acute in one region than another.

Where there is no nurse. Whether a result of a nursing shortage or changing demographics and care models, many experts agree that care traditionally provided by nurses will increasingly be provided by unskilled providers, including family members, friends, and other organized service delivery programs. In recognition of this fact, a 2001 Milbank Memorial Fund report on the decline in access to nursing care recommended that "government and private payers explore ways to support unpaid caregivers (for example, by providing tax incentives or subsidizing their own health coverage)"(Fagin 2001).



It is important to recognize two realities when addressing the nursing shortage in frontier and rural communities. First, solutions designed for urban areas will not work for rural areas; they must specifically address the nursing context in frontier and rural areas. Second, short term solutions that emphasize improving competitiveness will simply draw nurses away from somewhere else and exacerbate the shortage elsewhere - possibly rural and frontier areas. For example, in Montana, alumni surveys indicate that more nursing school graduates leave the state than remain employed in Montana (Goudiet 2004). "Grow your own" strategies that emphasize the unique context of providing care in frontier and rural communities are those with the best chance of reducing the frontier nurse shortage over the long term.

IV. NURSING IN FRONTIER AND RURAL COMMUNITIES

Literature suggests there are a number of factors that affect the nursing shortage in rural and frontier communities, including differences in education, practice setting, and practice within setting type. They also differ in terms of the populations they serve.

Education And The Rural/Frontier Nurse

Ongoing debates within the nursing profession address the extent to which rural nursing practice is different from mainstream (e.g. urban) practice (Trossman 2001; Brown-Schott, Britten et al. 2003; Crooks 2004). The questions - Is rural/frontier nursing a specialty? Do nurses require different preparation for a successful career in rural settings? If so, as many rural experts argue, one reason that rural areas may suffer disproportionately from the nursing shortage is that nursing schools lack rural/frontier curricula and clinical practice opportunities.



Recruiting nurses to work in rural areas is difficult to begin with; and, when urban-trained nurses enter rural practice, they often find they are ill-prepared for the demands of the job, contributing to job dissatisfaction and turnover. Once there, they typically find it difficult to access continuing education opportunities that fit their needs. "When educators bring their knowledge to us, they often do not realize that we practice differently than urban centers do" (rural nurse, quoted in Molinari 2001).

The rural nurse as "generalist-specialist." In the rural setting, nurses typically fill multiple roles. Organizational structures are typically more horizontal than vertical, suggesting the need for a broad range of skills and crosstraining in multiple jobs. "Rural nursing requires a high level of generalist skills and critical thinking" (Fahs, Findholt et al. 2003).

Access to education. The geography of higher education is mirrored by the geography of nursing practice. Registered nurses in rural practice are more likely than their urban counterparts to have graduated from ADN programs, largely because four-year and graduate degree programs are not available in rural areas (Szigeti 2000). And, while nurse employers express a preference for hiring BSNs, rural employers report greater difficulty in recruiting BSNs.



Rural nurses find it more difficult to obtain advanced degrees: in some areas, "anyone seeking another degree must move to the urban centers for their education" (Molinari 2001). Once trained in an urban setting, BSN graduates typically do not return to practice in rural areas. One study found that nurses who obtain BSN degrees receive less for their "investment" if they practice in rural areas than in urban areas (Pan and Straub 1997), so rural nurses have less of a financial incentive to obtain four-year degrees.

While rural nurses strive to turn around perceptions of lower quality of care in rural areas, the lower degree credentials of rural nurses and their difficulties in obtaining continuing education are suggestive of greater difficulty in raising standards of quality in rural nursing. Recent studies in hospital-based nursing link level of nurse education to quality of care (Aiken, Clarke et al. 2003). The American Association of Colleges of Nursing "believes that education has a significant impact on the knowledge and competencies of the nurse clinician" and advocates for a differentiated nursing practice model based on level of education (American Association of Colleges of Nursing 2003; see also American Association of Colleges of Nursing, American Organization of Nurse Executives and National Association for Associate Degree Nursing 1995). According to the AACN, "BSN nurses are prized for their skills in critical thinking, leadership, case management, and health promotion, and for their ability to practice across a variety of inpatient and outpatient settings," precisely the skills that proponents of a rural nursing specialty emphasize.

Importance Of Non-Hospital Based Nursing In Rural And Frontier Communities

Because most frontier and rural communities are distant from hospitals, residents may rely on non-hospital based care settings for a greater proportion of their care than their urban counterparts. For example, a school nurse may be the only skilled health care provider within a community. Thus, nurses serving in home health, public health, primary care, school health or faith-based settings are important resources in communities that may otherwise have no locally-based provider.



At the same time, these nursing roles are traditionally the lowest paid within the profession. With competition for fewer nurses driving up salaries and the inability of employers to compete with urban, high-tech hospital-based employers, the impending nursing shortage could further reduce access to the most basic of health care services.

Providing home care in rural or frontier areas comes with its own set of challenges. Longer travel times per client for rural home care nurses means that fewer clients can be visited in a day. Distance also means that follow up care with other providers is more challenging, if available at all. Clients are also isolated from other types of community support networks that are considered important for successful home-based care. These difficulties can discourage home care providers from accepting cases and result in more institutionalized care. A condition that may be considered appropriate for home-based management in an urban setting may be deemed too risky for a rural setting, particularly if evening and weekend nurses are not available.

Ethnic And Cultural Diversity of Rural And Frontier Populations

Minorities face a number of barriers within the profession, including access to education and job advancement. A recent American Nurses Association survey of minority nurses concluded that cultural differences often resulted in questions of competence, and a majority of African American, Hispanic, and Asian American/Pacific Islander nurses believed that they had been denied a promotion on the basis of race rather than education or experience (Adams 2002). Until recently, the nursing profession has not made a major effort to recruit minorities into nursing education programs, and professional disparities make it difficult to convince potential nursing students that nursing would be a good career choice.

In the U.S., racial/ethnic minorities represent 30% of the U.S. population, but only 12% of the nurse workforce (U.S. Department of Health and Human Services 2003). Data from the 2000 NSSRN shows that among frontier nurses, the proportion of minority nurses is even smaller: only 9% of frontier RNs reported a race/ethnicity different from non-Hispanic White (see Appendix A, Table 1).



The ethnic composition of the rural nurse workforce does not correspond with the population it serves. Although non-Hispanic whites still comprise more than four-fifths of the non-metro population, the non-metro growth rate of minorities between 1990 and 2000 was 29%, much higher than the overall non-metro growth rate of 10% (U.S. Department of Agriculture 2002). The greatest minority growth in non-metro areas was among Hispanics; three out of four states had increases of at least 50% in their non-metro Hispanic population and nearly half had increases of over 100%. Moreover, minority populations are not evenly dispersed; high concentrations of African Americans live in non-metro areas in the South and Southeast; Hispanics in the Southwest; and Native Americans in the West and Great Plains regions (Beale 2004). Among frontier and rural nurses, there is clearly need for more Native American and other non-white groups.

Other Practice Differences

Further issues faced by rural nurses are the result of the interaction between the rural setting, population characteristics, and health service delivery. The ANA Rural Nursing module identifies five factors that affect rural nursing practice: threats to anonymity and confidentiality; traditional gender roles; geographic isolation; professional isolation; and scarce resources (Bushy 2004).

Threats to anonymity and confidentiality affect both patient and professional; where nurses and patients are also friends and neighbors, familiarity has advantages (more holistic comprehensive care) but also disadvantages (lack of privacy for both patient and nurse; tendency to make assumptions based on familiarity). Traditionally-defined gender roles are also more common in rural areas, affecting expectations of provider-patient interaction; it also affects expectations regarding compensation for "women's work," where women traditionally fill unpaid roles as well as assuming responsibility for community-based volunteer work.

Geographic isolation affects more than access to care; the self-sufficiency and independence required of rural lifestyles can affect care and treatment decisions. Individuals whose physical status would render them home-bound in an urban context often see no choice but to find a way to remain mobile in the rural context; "non-compliant" behaviors result when practitioners lack an understanding of the necessity of rural patients to remain active. Isolation also restricts the professional interaction and support that a nurse may benefit from in urban areas. Although some nurses may enjoy the autonomy and creativity required by this isolation, others struggle with the lack of professional interaction and the stress of bearing so much responsibility.

Nursing practice in rural communities is also defined by an "ever-present scarcity of human and financial resources" (Bushy 2004). While scarce resources are a feature of any publicly funded service or institution, the resource base and scale of economy in rural areas exaggerates the lack of resources in rural communities. For nurses, this may mean that positions are funded only at a part-time level while they are expected to serve an entire county. The lack of resources also affects the availability of support staff, supplies and equipment, and services offered.





V. STRATEGIES FOR INCREASING THE SUPPLY AND RETENTION OF RURAL/FRONTIER NURSES

A number of strategies highlighted in this report are being used to address the nurse shortage crisis in rural and frontier areas, including education, retention and job satisfaction, service delivery, and policy. Some target specific issues, while others emphasize a more comprehensive, whole systems approach.

Education

	Develop rural-specific nursing curricula
	Provide innovative educational systems that enable in-place education and rural practicums
	Fund basic and advanced nursing education
	Make service commitments in rural underserved areas
	Introduce high school students to health service careers
	Target recruitment of minority and underrepresented groups

Retention and job satisfaction

	Develop service recognition programs
	Set standards for nurse employers and implement employer certification programs

Service Delivery

	Deliver services through telemedicine
	Use non-skilled providers (friend & family) to deliver personal care
	Use non-profit/volunteer organizations to establish and coordinate care networks

Policies

	Enable family/friends to be paid for providing personal care services
	Educate unskilled providers
	Offer a reimbursement differential for care providers to reduce the rural penalty

Further Challenges

While agencies are attempting to solve the nursing shortage crisis at many levels, strategies focus on removing professional barriers to recruitment and retention of nurses in rural and frontier communities. However, barriers also exist at the personal and community levels (Mason 2004). For nurses with families, limited employment and educational opportunities for spouses and children will continue to discourage rural practice. For single nurses, limited social opportunities may be a barrier, and the difficulties faced by "outsiders" finding acceptance in rural communities is a further challenge.

Rural and frontier communities experiencing difficulty in recruiting and retaining professional health care staff may discover barriers of a non-professional nature. A successful placement in a rural community hinges on both the nurse and the community. The way in which a new nurse is received within the community factors highly in a decision to remain. A true community-based effort aimed at removing personal and community barriers may require innovations in community organizing. A local nurse shortage may represent an important opportunity for community members to organize and actively transform their own communities. A community-based model for recruiting and retaining physicians may also benefit communities with other health practitioner shortages, including nurses (Shannon 2004).



VI. SUMMARY AND CONCLUSIONS

Frontier and rural communities are more likely to suffer from the national nursing shortage than their urban counterparts because (1) frontier and rural communities typically lack the economic resources to compete with urban-based employers, (2) nurses are typically not prepared for practice in non-urban settings, and (3) frontier and rural communities depend on non-hospital care settings to a greater extent than their urban counterparts; these practice settings are also disadvantaged relative to hospital-based practice. Urban-based strategies that emphasize competitive advantage may unwittingly exacerbate frontier and rural shortages.

One approach to increasing the supply of nurses in frontier and rural communities is a "grow your own" approach. Strategies include the development of rural-specific nurse education, in-place education, and funding for education targeted at underserved areas and groups. A second approach involves the use of technology to provide virtual services and increase the geographical reach of available nurses. A third approach is to is to identify a set of services traditionally provided by nurses that can be provided by available non-medical personnel (e.g. personal care providers, NGOs, community-based volunteers) - in essence, creating a class of non-medical providers that supplement nursing care, enable professional nurses to focus on more advanced nursing care, and provide the home care and community-based networks essential for good nursing outcomes in isolated communities.

Frontier and rural communities are innovators in the use of communications technology for both education of nurses and for provision of nursing services in communities that lack a provider. Distance education is a proliferating response to the demands of rural-based students to obtain in-place education, while telemedicine enables consultations with professional nursing staff in places that otherwise lack nursing services. The question of whether these relatively new modalities are seen as short-term responses to a crisis, or long-term, sustainable solutions that are as effective and acceptable as traditional, face-to-face modalities remains for future evaluation.

Finally, the health of a rural or frontier community is intertwined with its economic and social wellbeing. Nurse shortages in frontier and rural communities derive not only from the current national shortage of nurses but also a long-standing trend favoring rural-to-urban migration of the educated, skilled workforce. Although many rural communities are stable or even prospering, a great number are distressed, losing existing employment and education opportunities, and losing their people as a result. Approaches that ignore or fail to address the "health" of a community in a holistic sense cannot hope to resolve, over the long term, a nurse shortage crisis. Improving access to nursing care in frontier and rural communities means looking beyond a narrow focus on the nursing profession to a broader view of "workplace," that is, the community. Addressing the community context of a nurse shortage may require community-based development approaches as well as the crafting of healthy rural policies.




Footnotes

(1) Note: All references to "frontier" use the Consensus Definition of the Frontier Education Center unless otherwise indicated http://www.frontierus.org/index.htm?p=2&pid=6003&spid=6018. This definition has not been adopted by any federal programs but has been adopted as policy by the Western Governors' Association http://www.frontierus.org/documents/WGAPolicyResolution2004.htm and the National Rural Health Association. The Consensus Definition weighs three elements - population density, distance in miles and travel time in minutes - which together, generally describe the geographic isolation of frontier communities from market and/or service centers. The Frontier Education Center understands that various programs will establish their own programmatic definitions and eligibility criteria.

(2) County Public Use Data Files were obtained from HRSA/BHPr and analyzed in Stata 8.0 using SVR, a Stata module developed for complex survey data using replication methods (Winter, no date; Winter 2004). Per the survey documentation, a jackknife procedure (in the SVR module, the jk2 method) was used to produce weighted estimates (U.S. Department of Health and Human Services, 2002b). The income data are categorized; linear analysis of income is not possible.

(3) These issues are recognized by the Bureau of Health Professions. A new methodology for designating Nurse Shortage Counties is being developed (Jordan 2004).


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Crooks, K. (2004). "Is rural nursing a specialty?" Online Journal of Rural Nursing 4(1). Available (7/25/04) at http://www.rno.org/journal/issues/Vol-4/issue-1/crooks_column.htm

Domrzalski, D. (2003). NM home health care costs doubled last year. New Mexico Business Weekly. Albuquerque, NM. September 8. Available at http://albuquerque.bizjournals.com/albuquerque/stories/2003/09/08/story4.html?t=printable

eSchool News (2003). 'Internet nurses' serve rural schools' health needs. Available (7/16/04) at http://www.eschoolnews.com//news/showStory.cfm?ArticleID=4300&CFID=54756&CFTOKEN=96007990

Fagin, C. (2001). When Care Becomes a Burden: Diminishing Access to Adequate Nursing. New York, NY, Milbank Memorial Fund. Available (8/12/04) at http://www.milbank.org/010216fagin.html

Fahs, P. S., N. Findholt, et al. (2003). Themes and issues in rural nursing research. Teaching/Learning Activities for Rural Community-Based Nursing Practice. Helene Fuld Summer Institute for Rural Community Health Nursing. M. S. Collins. Binghamton, NY, Decker School of Nursing, Binghamton University: 156-172.

Franco, S. J. (2004). Medicare Home Health Care in Rural America. Bethesda, MD, NORC Walsh Center for Rural Health Analysis: 4 p. Available (7/25/04) at http://www.norc.uchicago.edu/issues/NseriesJan04v1.pdf

Frontier Education Center (2000a). List of Frontier Counties from 2000 U. S. Census. Available 6/20/04 at http://www.frontierus.org/index.htm?p=2&pid=6003&spid=6019

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Goudiet, T. (2004). Rainbow Project, Montana State University. Personal communication to T. Casados. 01/21/04.

Green, J. (2004). Parents protest nurse shortages. Rio Grande Sun. Espanola, NM: A8. Jan 1.

Greenbush (no date). Greenbush Presents: eNurse Consortium, Southeast Kansas Educational Service Center. Available (8/14/04) at http://www.greenbush.org/GBcentral_files/brochures/enurse_final.pdf

Health Resources and Services Administration (no date). The National Sample Survey of Registered Nurses 2000: Documentation for the County Public Use File. Rockville, MD, Health Resources and Services Administration, Bureau of Health Professions: 99 p.

Hecker, D. (2004). "Occupational employment projections to 2012." Monthly Labor Review Online 127(2): 80-105. Available (10/04/04) at http://www.bls.gov/opub/mlr/2004/02/art5full.pdf

Jacob, J. A. (2001). Looking for a few good RNs: Nursing shortage expands beyond hospitals, American Medical Association. Available (8/12/04) at http://www.ama-assn.org/amednews/2001/11/19/bisa1119.htm

Johnson, M. (2002). Scholarships target state nursing shortage. Available (8/13/04) at http://www.detnews.com/2002/careers/0207/29/c07-483835.htm

Jordan, A. (2004). Nurse shortage designation. Personal communication to J. Sherman. Washington, DC. 10/14/04.

LeBlanc, A. J., M. C. Tonner, et al. (2001). "State Medicaid Programs Offering Personal Care Services." Health Care Financing Review 22(4). Available (7/23/04) at http://www.cms.hhs.gov/review/01summer/01Summerpg155.pdf

Long, C. (2000). Rural communities feel sting of nursing shortage. The Daily Camera. Boulder, CO. Oct 9. Available at http://www.broomfieldnews.com/news/statewest/09lnurs.html

Magnuson, P. (2002). "Nursing necessity." Communicator 27(3): 1-7. Available (7/16/04) at http://www.naesp.org/ContentLoad.do?contentId=1095

Mason, W. A. (2004). "Oregon's Economic Crisis and the National Nursing Shortage: A Transformational Opportunity for Rural Areas." Online Journal of Rural Nursing 4(1). Available (07/25/04) at http://www.rno.org/journal/issues/Vol-4/issue-1/Mason_article.htm

MedPac (2001). Prospective payment for home health services in rural areas. Report to Congress: Medicare in Rural America. Washington, DC, Medicare Payment Advisory Committee: 103-110. Available (7/25/04) at http://www.medpac.gov/publications/congressional_reports/Jun01%20Ch6.pdf

Michigan Department of Labor and Economic Growth (2003). CIS presents $30,000 in nursing scholarships to six colleges & universities, State of Michigan. Available (8/13/04) at http://www.michigan.gov/cis/0,1607,7-154-10573_11472-63529--M_2003_3,00.html

Michigan Nurses Association (2003a). Two bills receive money; U.S., Michigan focus on nursing shortage. Available (8/13/04) at http://www.minurses.org/gov/Guide2003/twobills.shtml

Michigan Nurses Association (2003b). Michigan nursing scholarship fact sheet. Available (8/13/04) at http://www.michigan.gov/mistudentaid/0,1607,7-128-1724-54524--,00.html

Minnesota Department of Health (2001). Magnet Hospitals: A Positive Approach to Minnesota's Nursing Shortage. Report to the Minnesota Legislature. St. Paul, MN, Office of Rural Health & Primary Care, Minnesota Department of Health: 29 p. Available (8/20/04) at http://www.health.state.mn.us/divs/chs/rhpc/PDFdocs/magnet.pdf

Molinari, D. (2001). "Bridging Time and Distance: Continuing Education Needs for Rural Health Care Providers." Home Health Care Management & Practice 14(1): 54-58.

Montana State University-Northern (no date). The Rainbow Project, Department of Nursing, Montana State University-Northern. Available (7/23/04) at http://www.nmclites.edu/academics/nursing/rainbow2.htm

National Association for Home Care and Hospice (2003). Seeking stability in the medicare home health benefit - margins evaporate; agencies in financial jeopardy. Available (7/25/04) at http://www.nahc.org/NAHC/LegReg/03LL_HomeHealthSurveyRepor.pdf

National Association of School Nurses (2004). Issue Brief: School Health Nursing Services Role in Health Care: Reduction in Force. Available (7/16/04) at http://www.nasn.org/briefs/reduction.htm

Niesz, H. and P. Martino (2003). States that allow family members to act as personal care assistants. OLR Research Report to the Connecticut General Assembly. Available (7/23/04) at http://www.cga.state.ct.us/2003/olrdata/age/rpt/2003-R-0040.htm

Open Hands (2004a). Services and Programs. Available (9/17/04) at http://www.openhands.org/services.html#community

Open Hands (2004b). "Mobility restores pride." In Touch Spring/Summer: p. 7. Available (9/1704) at http://www.openhands.org/pdfs/news%20OH%20spr-sum04.pdf

Oregon Health Sciences University (1999). OHSU delivers nursing programs to rural students. Available (6/20/04) at http://www.ohsu.edu/news/archive/1999/111899rural.html

Pan, S. and L. Straub (1997). "Returns to nursing education: Rural and non-rural practice." The Journal of Rural Health 13(1): 78-85.

Personal Care Option Committee (2003). New Mexico Personal Care Option Program: Review and Recommendations. Santa Fe, NM, State of New Mexico, Human Services Department, and Medical Assistance Division: 35 p. Available (7/25/04) at http://www.state.nm.us/hsd/pdf/PCOCommitteReportFinal072003.pdf

Shannon, C. K. (2004). Community Approach to Recruitment and Retention. 27th Annual NRHA Rural Health Conference, San Diego, CA. Available at http://www.nrharural.org/HandoutPDFs/RuralRecruitmentFinal.pdf

Szigeti, E. (2000). "Educational Issues - Partnerships in Nursing Education." Online Journal of Rural Nursing 1(2). Available (7/22/04) at http://www.rno.org/journal/issues/Vol-1/issue-2/EdIssues_1_2.htm

Tabone, S. (2004). Texas Nurses Association, Nurse Friendly Program. Personal communication to J. Sherman. 8/27/04.

Tanner, C. A. (2001). Oregon's Nursing Shortage: A Public Health Crisis in the Making. http://www.frontierus.org/documents/WGAPolicyResolution2004.htm Portland, OR, Northwest Health Foundation: 29 p. Available (6/24/04) at http://www.oregoncenterfornursing.org/about/shortage.pdf

Texas Nurses Association (2004). Nurse-Friendly Hospital Criteria. Available (7/23/04) at http://www.texasnurses.org/wkplaceadv/nurse-friendly.htm

Trossman, S. (2001). "Rural nursing anyone? Recruiting nurses is always a challenge." The American Nurse. Available (7/24/04) at http://www.nursingworld.org/tan/01julaug/rural.htm

U.S. Department of Agriculture (2002). Race and ethnicity in rural America: The demography and geography of rural minorities, United States Department of Agriculture, Economic Research Service. Available (8/24/04) at http://www.ers.usda.gov/Briefing/RaceAndEthnic/geography.htm

U.S. Department of Health and Human Services (2003). HHS awards nearly $3.5 million to promote diversity in the nursing workforce. Available (7/20/04) at http://www.medicalnewsservice.com/ARCHIVE/MNS1772.cfm

U.S. Department of Health and Human Services (2002a). Projected Supply, Demand, and Shortages of Registered Nurses: 2000-2020. Washington DC, U.S. Department of Health and Human Services, Health Resources and Services Administration (HRSA), Bureau of Health Professions. Available (7/28/04) at http://bhpr.hrsa.gov/healthworkforce/reports/rnproject/report.htm

U.S. Department of Health and Human Services (2002b). The National Sample Survey of Registered Nurses 2000: Documentation for the County Public Use File. Rockville, MD, U.S. Department of Health and Human Services, Health Resources and Services Administration, Bureau of Health Professions: 99 p.

U.S. Department of Health and Human Services (no date). The Registered Nurse Population: Findings from the 2000 National Sample Survey, U.S. Department of Health and Human Services, Health Resources and Services Administration, Bureau of Health Professions, National Center for Health Workforce Analysis. Available (8/14/04/2004) at http://bhpr.hrsa.gov/healthworkforce/reports/rnsurvey/default.htm

Western Governors' Association (2004). Rural Health Improvements. WGA Policy Resolution 04-03. Santa Fe, NM. Available 7/22/04 at http://www.frontierus.org/documents/WGAPolicyResolution2004.htm

Winter, N. (2004). SVR: Stata module to compute estimates with survey replication (SVR) based standard errors (revised). Boston, MA, Statistical Software Components S427502, Boston College Department of Economics.Available (11/05/04) at: http://ideas.repec.org/s/boc/bocode1.html

Winter, N. (no date). Programs for Stata, Department of Government, Cornell University. Available (11/06/04) at http://falcon.arts.cornell.edu/nw53/progs.shtml