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thesis entitled

WHAT IS THE DIFFERENCE BETWEEN UTILIZATION OF THE ADVANCED
PRACTICE NURSE AS A HEALTH CARE PROVIDER AND GEOGRAPHIC
LOCATION OF RURAL COMMUNITY HEALTH CENTERS?

presented by

Lisa K. Bigelow

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Master of Science degree in Nursinq

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1m W14

WHAT IS THE DIFFERENCE BETWEEN UTILIZATION OF THE ADVANCED
PRACTICE NURSE AS A HEALTH CARE PROVIDER AND GEOGRAPHIC
LOCATION OF RURAL COMMUNITY HEALTH CENTERS?

BY
Lisa K. Bigelow

A THESIS
Submitted to
Michigan State University
in partial fulfillment of the requirements
for the degree of

MASTER OF SCIENCE IN NURSING

College of Nursing

1998

ABSTRACT
WHAT IS THE DIFFERENCE BETWEEN UTILIZATION OF THE ADVANCED

PRACTICE NURSE AS A HEALTH CARE PROVIDER AND GEOGRAPHIC
LOCATION OF RURAL COMMUNITY HEALTH CENTERS?

BY

Lisa K. Bigelow

As the cost for health care continues to skyrocket and
the number of primary and prenatal care providers declines
for rural Americans, the number of rural residents without
health care continues to increase. Utilizing advanced
practice nurses (APNs) in rural Community Health Centers
(CHCs) has been identified as a factor that will increase
access to rural health care. This secondary analysis
compared information about utilization of the APN by
geographic location in four regions of the contiguous United
States (US). The sample size consisted of 112 rural cues in
the contiguous U.S. Executive directors of the rural CHCs
completed a mailed survey. Results indicated that 91 of the
112 or 81% of the CHCs are utilizing APNs in their
facilities across the U.S. While there was not a
significant difference by geographic location and
utilization of the APN as a health care provider, the
results have positive implications for the APN as a provider

in meeting the needs of rural residents.

DEDICATION

This work is not mine alone. I have been blessed with
a wonderful family, supportive friends, colleagues,
professors and very special mentors without whom this could
not have been possible and would still be a distant dream.
A part of all of you is in this work that has been done.
Thank you for believing in me. This is dedicated to all who
have touched my life and have helped me grow into the person

I am and who I will be.

iii

ACKNOWLEDGMENT

Special thanks to my committee: Mildred Omar, PhD, RNC,
Chair, Rachel Schiffman, PhD, RN, and Jacqueline Wright,
MSN, RN, for your expertise, patience, and knowledge. Your
time has been well spent and greatly appreciated. Each of
you has provided me with pearls of knowledge that I will
carry throughout my life and pass on to others.

I want to thank my colleagues and mentors: Vicki
Chessin, MD, Gregg Stefanek, Do, and Jim Hall, MD, the gifts
of your trust, knowledge, encouragement, unending support,
and belief in me to achieve this goal still have me in awe.
I truly could not imagine attempting and attaining this
goals without your help.

None of this would have been possible without my
family. To my mother and sister, Laurie, my hero and role
model, thank you for your never ending love, faith, and
support to complete this project. My deepest thanks to my
husband, Jeff, my partner for life, for his support and
willingness to be mom and dad for a while. Finally to my
children, Kenny, Bethany, Kathryn, and Andrew, for your
unconditional love and belief in my completion of this goal.
You four are my greatest achievement and motivation to

complete this project.

iv

INTRODUCTION . . . . . . . . .

CONCEPTUAL FRAMEWORK . . . . . . . . . . . . . .

METHOD . . . . . . . . . . . . . . . . .

RESULTS I O O O O O O O O O O O O O 0

TABLE OF CONTENTS

LIST OF TABLES . . . . . . . . . . . . . . . . . . . .

LIST OF FIGURES O O O O O O O O O O O O I O O O O O O 0

Background of the Problem
Statement of the Problem .
Research Question . . . .
Hypothesis . . . . . . . .

Conceptual Definitions of Study Variables . .
Utilization of the APN as a Health Care Provider
Geographic Location of Rural CHCs . . . . . . .
Conceptual Framework by Starfield . . . . . . .

REVIEW OF LITERATURE . . . . . . . . . . . . . . . .

Geographic Location of Rural CHCs . . . . . . . .

Utilization of the APN . . . . . .

Geographic Location of Rural CHCs and Utilization
of APNs . . . . . . . . . . . . . . . . . . . . .
Critique of Literature Review . . . . . . . . . .

Research Design . . . . . . . . . .
Sample . . . . . . . . . . . .

Operational Definition of Variables
Instrumentation . . . . .
Data Analysis . . . . . .
Assumptions of Study . . .
Limitations of Study . . .
Protection of Human Subjects

Description of Sample . . . . . . .
Analysis of Research Question . . .
Hypothesis . . . . . . . . . . . . .

DISCUSSION . . . . . . . . . . . . . . . . . . . . . .

Sample . . . . . . . . . . . . . . . . . . . . .
Discussion of Results with the Conceptual
Framework . . . . . . . . . . . . . . . . . . . .
Implications for Advanced Practice Nursing and
Primary Care . . . . . . . . . . . . . . . . . .
Recommendations for Further Research . . . . . . .

SUMMARY . . . . . . . . . . . . . . . . . . . . . . . .

LIST OF REFERENCES . . . . . . . . . . . . . . . . . .

Page
vii

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TABLE OF CONTENTS (cont.)

Page

APPENDIX A: Provisions of Prenatal Care by Rural CHCs
in the United States . . . . . . . . . . . . 48
APPENDIX B: Letter of Approval from UCRIHS . . . . . . . 49
APPENDIX C: Original Study UCRIHS Approval . . . . . . . 50

vi

LIST OF TABLES

Page
Table 1: Frequencies of Sample Rural Community Health
Center Characteristics . . . . . . . . . . . . . 36
Table 2: Cotingency Table for APNs Employed in Rural
CHCs That Provide Prenatal Care and Geographic
Location of Rural CHCs in the United States. . . 37

vii

LIST OF FIGURES

Figure 1: U.S. Census Bureau Regions . . . . . . . . . .
Figure 2: An Adapted Conceptual Framework for

Evaluation of Rural Health Care from Starfield's
Model of Health Services System . . . . . . . . 21

viii

INTRODUCTION

WW

As the cost of health care continues to skyrocket and
the number of primary care providers, including prenatal
care providers, declines for rural Americans, the number of
rural residents without health care continues to increase.
Rural residency has been identified as a factor affecting
access to prenatal care (Edelman & Henz, 1996; Kohler, 1994;
Lucas & Rosenthal, 1992). A decrease in prenatal care
providers in rural settings is compounded by providers not
offering prenatal services due to changes in practice, lack
of specialists in these rural settings, and physicians
choosing to stop or reduce services (Xohler, 1994;
McClanahan, 1992; Rivo & Satcher, 1993; Schleuning, 1991).
The advanced practice nurse (APN) practicing within rural
Community Health Centers (CHCs) has been identified as a
factor which increases access to prenatal care for rural
populations (Inglis & Kjervik, 1993; Kohler, 1994).

The APN has encountered difficulty at times, practicing
in rural settings for various reasons, including physicians'
and consumers' lack of knowledge about the APN role, and
legal barriers (Brown & Grimes, 1995; Inglis & Kjervik,
1993; Xviz, Hisner, & Vinson, 1983). As knowledge of the
APN's role in health care increases, acceptance and
utilization of the APN increases (Sabo & Louis, 1996). With
the decline in rural prenatal care over the last decade
(McClanahan, 1992; Schleuning, Rice, & Rosenblatt, 1991),

1

it is important to examine the utilization of the APN in the
rural communities throughout the United States.

The purpose of this study was to determine if there
were differences in APN utilization for health care in rural
CHCs in the U.S. by geographic location. Utilization of the
APN in separate geographic locations may vary due to the
unique culture of the region, availability of health care
based on distance or number of providers in a given area,
and the scope of practice of the APN.

Community Health Centers (CHCs) provide comprehensive
primary care services including prenatal care to medically
underserved populations of which rural populations are a
part. Increased accessibility to health care for rural
residents can be addressed through the use of APNs in rural
settings (Conway-Welch, 1991). Rural community health
centers need, however, to be willing to utilize and accept
APNs in the delivery of health and prenatal care services
within their rural communities. Literature supports the use
of APNs in rural areas (Inglis & Kjervik,‘1993; Kviz et al.,
1983; McGrath, 1990). Identifying the geographic location
where APNs are employed could identify patterns of APN
utilization and gaps where APNs could favorably impact
accessibility of health care services in rural areas.
W

Rural residency is often a barrier to accessing
adequate prenatal care. Geographic location (Office of
Technology Assessment [OTA], 1990; Public Health Service,
1990) and shortage of providers (Kohrs & Mainuos, 1996) are

2

factors with which rural citizens contend when seeking
prenatal care in their rural communities. There are more
than 61 million people living in rural settings (U.S. Census
Bureau, 1996). Availability of prenatal care providers in
rural areas has declined (Bamberg, Halvey, Wainright,
Fottler, & Joiner, 1994; Rivo 8 Satcher, 1993). One
solution to increase availability of prenatal care providers
in rural areas is through the use of non-physician
providers, more specifically the use of APNs. Advanced
Practice Nurses are frequently more willing to work in
underserved areas and are less costly providers of prenatal
care (Buppert, 1995; Inglis & Xjervik, 1993; Hahoney, 1988;
McGrath, 1990; OTA, 1990; Sekscenski, Sansom, Bazell,
Salmon, & Mullen, 1994; Shi, Samuels, Ricketts, 8 Konrad,
1994). Utilization of APNs in rural areas has increased
prenatal care utilization (Levine, Orr, Sheatsley, Lohr, 8
Brodie, 1978; OTA, 1990; Shi et al., 1994). APNs have been
shown to provide quality prenatal care equivalent to
physician care with equivalent outcomes (HcGrath, 1990).
However, some areas of the country are not utilizing APNs
to the fullest extent (Buppert, 1995). Some of the
influencing factors of utilization of the APN include:
reimbursement issues, scope of practice of the APN in a
particular state or region of the US, and whether or not the
APN has prescriptive privileges.

Examining utilization of the APN by geographic location
is relevant due to regional differences which might account
for variations in the utilization of APNs. Regional

3

differences include availability of health care providers,
scope of practice of the APN, insurance coverage, access to
health care, population, income, health status, employment
status, type of industry, and agricultural area. Analysis
by region will offer information about the needs of the
rural regional populations. The information gathered may
provide insight about utilization of the APN.

Access to prenatal care is a national issue with
growing concern over the decreasing number of prenatal care
providers in rural areas. The APN as a health care provider
can fill the gap for the prenatal care needs in rural
communities. There is limited research on utilization of
health care providers by geographic location. This study
will provide descriptive information about the utilization
patterns of APNs in health care by geographic location in
rural CHCs across the United States. This will provide
vital information to health planners and policy makers to
help promote increased utilization of the APN as health care
providers, including prenatal care, in rural areas.

This study examined utilization of APNs as health care
providers in rural CHCs by geographic location. A secondary
analysis using primary data collected by Omar, Schiffman,
and Hogan (1997) was done. In the primary study, consenting
executive directors of rural CHCs were asked to complete the
Partnership for Rural Prenatal Care Delivery Survey. The
completed survey provided information about the type of
health care providers at the rural CHCs, as well as current

staff profiles.

33W

Are there proportional differences by geographic
location of rural community health centers and utilization
of the advanced practice nurse for health care?
mum

There will be a difference in utilization of the APN as
a health care provider in rural CHCs by geographic location.

Conceptual Framework

W

This section includes the conceptual definitions of the
study variables, followed by the conceptual model used in
this study. Starfield's Health Services Model (1992) was
used and is described. The concepts, utilization of the APN
as a health care provider and geographic location of rural
CHCs are conceptually defined.
WW

An APN, or advanced practice nurse, is defined as
either a certified nurse midwife or nurse practitioner.
Advanced practice nurses can practice in a variety of
settings within the health care arena, including rural CHCs.
Nurse practitioners and certified nurse midwives more often
practice in primary care settings providing prenatal and
primary care (Inglis & Kjervik, 1993; OTA, 1990; Towers,
1990). Advanced practice nurses have a minimum of a
Bachelors in Nursing degree which provides them with basic
knowledge and skills. Usually the APN has a Masters degree.
Advanced practice nurses are licensed, certified and can
work independently or collaboratively with other members of

5

the health care team. Licensure of the APN is through a
state license to practice as a registered nurse followed by
a national certification to practice as an advanced practice
nurse. Advanced practice nurses are educated to manage
acute and chronic health problems, with a focus on
preventative and health maintenance care, and psychosocial
issues affecting the patients' health (Inglis 8 Kjervik,
1993). The APN as a prenatal care provider for low risk
pregnant women fits within the scope of the APN's practice.

For the purposes of this study, utilization of the APN
was defined as the employment of the APN in rural CHCs for
the provision of health care to the community being serviced
by the rural CHC.

3 l' I l' E E J :H:

Geographic location of rural CHCs was defined for the
use of this study, by state and/or region of the United
States defined by the US Census Bureau (See Figure 1). The
four regions in the U.S. that were utilized in this study
were: West, Mid-West, South, and North-East. Each region
has it's own characteristics related to access to health
care, rural status, health care coverage, poverty status,
health status, and practice environment for APNs. Each are
described by region. The West has 11 contiguous states,
Hawaii and Alaska are also included in this region by the
Census Bureau, although these two states were not included
in this study. This region can be mountainous, desert, or
rich farm land with a lot of open space and sparsely
populated areas. With exception of the major cities, the

6

 

Mid-West North-East

   

Figure l. U.S. Census Bureau Regions

Western region's livelihood stems from ranching, tourism,
and mining. This region has 34% of the nation's total
population and is the most urban of the four regions with
only 14% rural population (U.S. Census Bureau, 1997).
However, a regional average population density of 39 people
per square mile causes 91% of the counties in this region to
be designated as Medically Underserved Areas (MUA) and/or
Health Provider Shortage Areas (HPSA) in 1996 (Bureau of
Primary Health Care [BPHC], 1996). More than 71% of the
region's total counties are non-metropolitan MUA and/or HPSA
in this region (BPHC, 1996). Eleven percent of the
population was over 65, 29% were under 18, and 60% were
between 18 and 64 years of age (BPHC, 1996). Population by
age across the nation was similarly distributed and varied
slightly for all four regions.

Of the four regions, the West had the second highest
percent of people without access to primary care at 11%
(above the national average of 10%) and the lowest percent
of family physicians practicing primary care by region at
21% (Morgan, Morgan, 8 Uhlig, 1998). This region was also
found, in comparison to the other three regions, to have 40%
of primary physicians practicing prenatal care but the
lowest percent of women entering prenatal care in the first
trimester at 72% (below the national average of 82%) (Morgan
et al., 1998). These statistics indicate the Western region
has significant gaps in health care. These gaps are seen in
relationship to availability of providers and the
distribution of pOpulation density throughout the region.

8

The Western region was also found to have the second
highest percent of persons not covered by insurance at 16%
(above the national average of 15%), with the lowest percent
of Medicare recipients at 13% (below the national average of
14%), and second lowest percentage of Medicaid recipients at
11% (below the national average of 13%) in comparison to the
other regions (Morgan et al., 1998). The Western region was
found to have the second highest percent of people below
poverty level at 15% and the second lowest median household
income at $33,730 (below the national average of $33,877)
(Morgan et al., 1998). This region tends to be relatively
poor, lacking access to health care, and not largely
dependent on public insurance in comparison to the other
three regions of the Us.

The health of the Western region in comparison to the
rest of the nation, however, was superior. Assessment of
health was determined by reviewing state statistics for
death rates related to disease, then averaged by region
(Morgan et al., 1998; U.S. Census Bureau, 1997). The
Western region was below the national average for the
majority of diseases reviewed including, heart disease,
cancer, cerebrovascular accidents, diabetes, HIV, and
homicide (Morgan et al., 1998). Diseases that were above
the national average for the western region were: motor
vehicle accidents, accidents/adverse effects, chronic lung
disease, and suicide (Morgan et al., 1998).

The practice environment in the Western region for APNs
is positive. Legal authority of the APN in the Western

9

region is the best of the four regions with 64% of APNs able
to practice independently and 91% able to practice
independently or with supervision (Pearson, 1997). The
scope of practice is determined by the Boards of Nursing
within the states of the practicing APNs. Prescriptive
authority of the APN is ranked second of the four regions
with 64% (46% prescribing controlled substances) of APNs
being able to prescribe independently, and 100% of the APNs
within the region able to prescribe either with supervision
or independently (Pearson, 1997).

The Mid-Western region consists of 12 states, including
the Great Lakes area (U.S. Census Bureau, 1996). This area
has a combination of flat lands and rolling hills, with
access to the ocean through the Great Lakes. The sources of
livelihood for this region includes a diverse and unique
combination of industry and agriculture, including shipping
and farming. This region also has both the Ohio and
Mississippi rivers bordering for waterway access to the
oceans. There is a combination of large metropolitan areas
and more densely populated areas than the West and sparsely
populated rural areas of farm land (Encarta, 1996). The
Mid-Western region has 23% of the nation's population and is
more rural at 28% than the West and the North-East (U.S.
Census Bureau, 1997). An average of 81% of the counties in
this region are MUS and/or HPSA, this is due to an average
population density of 94 people per square mile (BPHC, 1996)
demonstrating the ruralness of this region. Thirteen
percent of the Mid-Western regions' population is over 65,

10

28% are under 18, and 59% are between 18 and 64 years of age
(BPHC, 1996), indicating a slightly higher elderly rate than
the West, but marginally lower than the South and the North-
East.

Access to primary care in the Mid-Western region was at
10% ranking second in the four regions and third with 23% of
the family physicians practicing in primary care across the
nation (Morgan et al., 1998). The Mid-West ranks first for
family physicians practicing obstetrics at 48% and is the
second ranked region for women entering prenatal care in the
first trimester at 84%. The Mid-Western region has greater
access to health care and better access to prenatal care.

The Mid-Western region ranked the lowest of the
uninsured of the four at 10% with the lowest percent of
Medicaid recipients at 10% (below the national average of
13%) and the second highest percent of Medicare recipients
at 15% (above the national average of 14%) (Morgan et al.,
1998). The Mid-Western region had the lowest percent of
people under the poverty level at 11% (below the national
average of 14%) and a median household income of $34,495
(above the national average of $33,877) ranking second of
the four regions (Morgan et al., 1998). This region is
relatively wealthy, with good access to health care, more
likely to be insured, and not as dependent on public
insurance, but with more Medicare utilization.

The general health status of the Mid-Western region is
poorer than the West and North-East, but comparable to, if
not slightly better than the South. The Mid-Western region

11

was higher than the national average for all diseases: heart
disease, cancer, accidents/adverse effects, MVAs, chronic
lung disease, and diabetes, except HIV, and with less
violence than the national average for suicide and homicide
(Morgan et al., 1998). The higher than national average
statistics for disease indicate more chronic conditions seen
in the elderly, those with sedentary lifestyles and stress
related conditions.

The Mid-Western region has the least desirable practice
environment for APNs of the four regions. The APN has the
lowest legal authority in this region with 42% of the APNs
able to practice independently; however, 92% of APNs
practicing have prescriptive authority in this region
(Pearson, 1997). Of the APNs with prescriptive privileges,
73% have controlled substances privileges (Pearson, 1997).
The APNs in one state in this region do not have any
prescriptive privileges (Pearson, 1997).

The South has a unique culturally diverse region with
16 states bordering the Gulf of Mexico and the Atlantic
Ocean (U.S. Census Bureau, 1996). The culture of this
region varies from the French Creole, to the mountain people
of the Smoky Mountains. Livelihood in this region includes
oil industry, harvesting and producing; agricultural sources
include; cotton, tobacco, and citrus fruit. Tourism and
fishing industry are significant sources for the coastal
states and Florida. There is a range of densely populated
areas to sparsely populated areas especially in the
mountainous western portion of the region. The Southern

12

region has 22% of the nation's population and is the most
rural of the regions with 31% of the regions population
being rural (U.S. Census Bureau, 1997). The average
population density of this region is 142 people per square
mile. This region has the most states, with 90% of the
counties designated MUA and/or HPSA. More than 69% of the
total counties are non-metropolitan MUA and/or HPSA in this
region (BPHC, 1996). Almost 14% of the Southern region's
population is over 65, 27% are under 18, and 60% are between
18 and 64 years of age (BPHC, 1996). The Southern region
has the second highest percent of people over 65 of the four
regions.

Health care in the Southern region is the bleakest of
the four regions, with the exception of 31% of physicians in
primary care practicing in the South (Morgan et al., 1998).
The South has the highest percent of persons without access
to primary care at 13%, the lowest percent of family
physicians providing prenatal care at 17% (far below the
national average of 30%), and the second lowest percent of
women initiating prenatal care in the first trimester at 82%
(Morgan et al., 1998). These statistics strongly indicate
gaps in primary care for the Southern region through the
lack of prenatal care providers and access to health care.
The large rural population in the region would experience an
accentuation of the health care problems identified above
and greater gaps in care.

The Southern region also has the highest percent of
uninsured people at 17%, the highest percent of Medicaid

13

recipient at 15%, and the second lowest percent of Medicare
recipients in the nation at 15% (Morgan et al., 1998). The
Southern region has the highest percent of people below the
poverty level at 16% and the lowest median household income
of the four regions at $30,339 (below the national average
of $33,877)(Morgan et al., 1998). This region has the
highest dependency on public insurance and the greatest
poverty of the four regions.

The health of the Southern region is also the lowest in
comparison to the other regions. The Southern region was
found to be higher than the national average in all diseases
reviewed, except HIV (i.e., heart disease, cancer, CVA,
accident/adverse effects, MVA, chronic lung disease,
diabetes), and a greater incidence of violence being higher
than the national average in suicide and homicide
percentages. These outcomes are results of poor access to
primary and prenatal care, less availability of health
insurance, and poverty.

The major health problems of this region are chronic
diseases that have not been attended due to lack of access
to care, basic primary care, mental health, and prenatal
care. The Southern region exemplifies the rural health
picture when needs are not being met. Although this region
has the highest percent of primary care physicians in the
nation, the South is the largest and with greater divergence
between the rural and urban areas in the four regions.
Health status of this region is better measured by the
greater percentage in lack of access to health care and the

14

poorer health outcomes of the region in comparison to the
other regions.

The practice environment for the APN in the Southern
region is ranked third in the four regions, behind the West
and the North-East, but better than in the Mid-West. The
legal authority of the APN in the Southern region has 31% of
the APNs able to practice independently and 75% able to
practice with supervision or independently with scope of
practice being determined by the states' Board of Nursing.
Prescription authority in this region is 100% independent or
supervised, with 66% able to prescribe controlled
substances, and 19% are independent prescribers. While this
region does have more limitations for the APN, it is less
restrictive than the Mid-West. The Southern region has a
great need for health care providers and the APN would be
utilized in this region readily based on the needs
identified here for access to primary and prenatal care, and
indigent care.

The North-Eastern region consists of nine states that
are densely populated and highly industrial (U.S. Census
Bureau, 1996). The sources of livelihood are mostly
fishing, shipping, and manufacturing. Of the four regions,
the North-Eastern region has 19% of the nation's population
and the second lowest rural population at 21% (Morgan et
al., 1998). This region is the most densely populated at
453 people per square mile. However, 88% of the counties in
the North-East region are MUA and/or HPSA indicating a high
number of areas that are rural in this region (BPHC, 1996).

15

An example of the diversity in population in this region is
comparing New York City or Boston which are both densely
populated and with cutting edge technology for health care
to up-state New York or Western Massachusetts, very rural,
sparsely populated areas, with limited access to health care
due to the distance and availability of health care
providers for these communities. The contrast of these
rural and urban areas are extremes found within same states
are characteristic for this region. Fourteen percent of the
population of this region is over 65, with 25% being under
18, and 61% between 18 and 64 years of age (BPHC, 1996). In
comparison to the other three regions, the North-East has a
slightly higher elderly population and adult population.

The North-East has the greatest access to health care
of the four regions with the lowest percentage of people
without access to health care at 8% and the second highest
percent of physicians in primary care at 25% in the nation
(Morgan et al., 1998). Although the percent of family
physicians providing prenatal care in this region ranks
third at 27, the women entering prenatal care in the first
trimester is the highest of the four regions at 86% (Morgan
et al., 1998). These statistics indicate less gaps in
health care in comparison to the other three regions.
However, gaps are present and would more readily be seen in
the rural communities of this region that may be overlooked
due to population density and health care availability found

in parts of this region.

16

The North-Eastern region has the second lowest percent
of uninsured people in the nation at 13%, the highest
percent of Medicare recipients at 16%, and the second
highest percent of Medicaid recipients at 12% (Morgan et
al., 1998). This region has the second lowest percent of
people below the poverty level at 13% and the highest median
household income at $36,945 (above the national average of
$33,877). This region tends to be wealthier, more likely to
‘be insured, with good access to health care, and more
dependent on public insurance.

The health status of the North-Eastern region is mixed
and could be classified as, not as bad as the South, but not
as good as the West, and slightly better than the Mid-West.
In the North-Eastern region the diseases that were higher
than the national average were heart disease, cancer,
diabetes, and HIV (Morgan et al., 1998). This region was
lower than the national average for CVA, accidents/adverse
effects, MVAs, and chronic lung disease (Morgan et al.,
1998). Surprisingly, this region was lowest for violence of
the four regions, both suicide (9%) and homicide (6%) were
below the national average at 12% and 10% respectively
(Morgan et al., 1998). Major health problems of this region
would include, stress related health problems, HIV and AIDS
related complexes. Health promotion, disease prevention,
HIV and AIDS clients, and elder care would be utilized by
this regions population. The rural issues of this region
may include more HIV/AIDS care than in other regions and
prenatal care.

17

The practice environment for the APN is excellent in
the North-East. Legal authority of the APN in the North-
Eastern region has 67% of APNs practicing independently and
89% either independent or supervised privileges with the
states' Boards of Nursing defining the scope of practice
(Pearson, 1997). Prescriptive authority of the APN in the
North-Eastern region is also highest of the four regions at
100% having either independent or supervised privileges,
including controlled substances (89%) (Pearson, 1997). Only
one state, New Jersey, is without prescriptive privileges
for controlled substances (Pearson, 1997). Although the
practice environment is excellent, utilization of the APN
may be lower in this region due to the larger percentage of
primary physicians practicing and the smaller size of this
region, greater access to health care, more insured and
wealthy population. However, there is great value for the
APN in this region and is seen through the development of an
excellent practice environment for the APN. The contrasting
extreme rural communities have need for APNs to fulfill the
gaps in health care.

Rural health care needs to be addressed. Nearly one in
four persons live in rural communities across the United
States (U.S. Census Bureau, 1997). All four regions
experience lack of access to health care, with three of the
four regions above the national average of 10%; the North-
East is the only region below the national average at 8% of
the population without access to health care (Morgan et al.,
1998). Nationally, less than half of the family physicians

18

are providing prenatal care. First trimester initiation of
prenatal care is 82% nationally, indicating almost 20% of
women in the US are entering prenatal care late (Morgan et
al., 1998). The regions with the most rural populations
(West and South) have the most people below poverty level
and are the least insured (Morgan et al., 1998).
Utilization of the APN in these communities can narrow the
gaps in health care for rural populations.

WW- Rural CHCs were
developed in the 1960's as part of the War on Poverty issues
of the Federal Government. CHCs are responsible for
providing primary health care to those with limited income
or access to health care. The philosophy of the CHC is to
service everyone within a designated area, regardless of
economic status, providing quality basic health care. Rural
CHCs are organized operations that provide comprehensive,
coordinated, preventative and community based primary health
care services, including prenatal care, to rural clients.
The CHCs are characteristically found in medically
underserved areas and/or health provider shortage areas
designated by the Federal Government across the U.S.
Community Health Centers are located in both urban and rural
areas.

Definitign_gf_nnzal. The literature defines rural as
the geographic area and/or the density of the population.
Various definitions exist in the literature for rural. Some
sources indicate ruralness is based on number of people per
square mile, population of less than 50,000, populations

19

less than 10,000, or based on designation of metropolitan
statistical area or non-metropolitan statistical area (BPHC,
1996; Goldsmith et al., 1993; U.S. Census Bureau, 1996).
Rural areas are characteristically sparsely populated, and
usually, distanced from metropolitan areas and underserved
due to geographic location and availability of providers
(BPHC, 1996; Goldsmith et al., 1993; U.S. Census Bureau,
1996).

For the purpose of this study, geographic location of
rural CHC was defined as the four regions in the US (West,
Mid-West, South and North-East) where rural CHCs are located
and which represent characteristically diverse rural
regions.

W

The conceptual framework for this study was adapted
from Starfield's Health Services Model (1992) (See Figure
2). Starfield (1992) defines primary care as the first
contact with the health system offering continuous,
longitudinal, comprehensive, and coordinated health care.
This basic health care service should be available equally
to every person in the U.S. The provision of primary care
can maximize the health status of the individual through
health promotion, disease prevention, and treatment of
disease or illness. This framework is used to measure the
attainment of primary care. Every health system has three
components: structure, process, and outcome. Starfield

describes the approach for measuring primary care, including

20

A Basis for Evaluation of Rural Health Care

 

Rural Community Health Centers

Personnel

0 APN Utilization
Facilities/equipment
Range of services E
Organization
Management and amenities
Continuity
Accessibility
Financing
Population eligible

 

STRUCTURE

J

 

 

 

Problem recognition
Diagnosis
Management
Reassessment

 

V

— r ‘1 *
PROCESS PERSONS H and

I. __f__ ————— -l physical
Utilization environment
Acceptance . Geographic

Satisfaction Location
K Understanding

Participation
Activity

Comfort

OUTCOME Perceived well-being ‘—
Disease
Achievement
Resilience

 

 

 

 

 

 

 

 

 

 

 

 

 

Longevity

 

 

 

 

Eigmz. An Adapted Conceptual Framework for Evaluation for Rural Health Care
from Starfield's Model of Health Services System. Source: Starfield, 1992.

21

prenatal care, based on structure and process in the health
services systems.

Structure of care is the actual resources (Starfield,
1992) utilized in a health services system for delivery of
care: facilities and equipment, range of services
organization, management and amenities, continuity,
accessibility, financing, and population eligible. The
structure of a rural CHC would include all of the stated
resources. In this study, the focus was on personnel and
whether APNs were utilized in rural CHCs. Personnel is
defined by Starfield as the people involved in providing
services in the health care system.

The social and physical environment also affects
utilization of the APN. Rural CHCs are designed to meet the
needs of medically underserved and health provider shortage
areas across the U.S. The physical environment, or
geographic location, potentially affects the outcome of
health in the health services system described by Starfield.
The geographic location can affect utilization of the APN
based on the distribution and needs of the population of the
specific rural region or location. The four regions offer
diverse and specific health care needs based on the cultural,
industrial, and geographic layout of each region as well as
each region's own unique characteristics related to access to
health care, rural status, health care coverage, poverty
status, health status and practice environment for APNs.

Geographic location of rural CHCs throughout the U.S., as

22

part of the physical environment, will offer information
about utilization patterns of APNs in the four regions.

Although process of care is not addressed in this study,
it is important to understand how it fits into the health
services system. The process of care is the activities of
the provider and the client during the services. The client
decides whether or not to utilize the services of the health
care system. The APN determines through a complete health
history and physical assessment, the problem affecting the
client, diagnoses, formulates and implements a management
plan of care with the client and follows with reassessment to
evaluate the outcome of the plan of care and revises the plan
accordingly. Once the client utilizes the services, a
decision is made by the client as to satisfaction with the
collaborative plan of care and acceptance of this care based
on the client's understanding of the problem and plan. The
client's participation in the plan of care is the key for the
primary care system to function effectively.

While outcome of care is not the focus of this study, it
is important to see how this relates to the health services
system. Outcomes are the direct or indirect results of the
activities of the provider, services provided to the client,
and how the client chooses to participate in the services and
recommendations offered by the provider. Advanced practice
nurses are capable of providing quality care equivalent to
physician providers with equivalent outcomes (Shi et al.,

1994).

23

Review of Literature

This section examines the empirical literature related
to the variables under study, geographic location of rural
CHCs and utilization of the APN. There is relatively little
empirical literature relevant to utilization of the APN
associated with geographic location in general and scant
literature associated with geographic location of rural CHCs
specifically. Some studies have been done on utilization of
the APN and only a few studies on geographic distribution of
the APN. Utilization by geographic location allows the
unique health care needs of rural communities to be addressed
and met. 'Barriers to utilizing APNs in rural communities
need to be analyzed. The ability to positively influence
political leaders with accurate data based on geographic
location would be highly valued.
W

A very limited number of empirical studies have been
done which examined APN utilization and geographic location;
no recent studies were found in the literature. Most of the
studies focused on the education, barriers to practicing and
recruitment of APNs to rural locations or areas of high need
for primary care providers (Anderson, Gilliss, & Yoder, 1996;
Bigbee, 1992; Inglis & Kjervik, 1993; Wirth, 1977). The
missing piece to geographic location is what is currently
happening across the nation with actual APN utilization.

Wirth et al. (1977) did an analysis of graduates from a
pediatric nurse practitioner program (PNP) (n=50) at a
university in Missouri. The purpose of the study was to

24

determine the geographic distribution of the graduates and
the factors affecting their choice of location. Of the 50
graduates, 41% stated a preference for location (rural or
urban) as a motivating factor for employment. This
motivating factor was the second most frequent choice, with
the opportunity to work with a specific institution being
first. Limitations of this study include the population of a
specialty group, and the small sample size from one area of
the country limiting the generalizablity of the study. The
method of the survey was not identified, nor were the
locations of the PNPs practicing outside the state. The
study did not offer information about utilization of the PNPs
by geographic location and is more than 20 years old.
Goldberg, Hafferty, and Fowkes (1984) studied the
distribution of APNs and PAs in the state of California with
the influence of the type of clinical experience during the
education process. The population was graduates (n=172)
from a Primary Care Association Program. Based on the
clinical location of the student, "community graduates"
(Graduates from Stanford University who had their clinical
experience in one of five outlying training sites rather than
in the San Francisco Bay area) were twice as likely to
practice ”outside the San Francisco Bay area" and in
communities with a population of less than 10,000 when
compared to the university graduates with clinical experience
in the San Francisco Bay area. The focus of this study was

on the education and recruitment away from the university

25

setting to increase the supply of practitioners to the
outlying areas.

Limitations of this study include the dated study and it
is limited to one population in a small area limiting the
generalizablity. Details about the rural community APN
utilization were not addressed in this study, but could have
been helpful in developing strategies to meet the needs of
these rural populations.

WEN

Empirical literature about utilization of the APN
focuses on the perception of tasks the APN is able to perform
to physicians' satisfaction (Levine et al., 1978; Schaffner,
Ludwig-Beymer & Wiggins, 1995), the presence or absence of
barriers to practice environments affecting utilization of
the APN (Sekscenski et al., 1994), and descriptive data about
the types of APN practices currently utilized in different
settings (Schaffner et al., 1995; Shi et al., 1994).
Utilization of the APN as a prenatal care provider has not
been studied in the recent literature. Some possible
explanations for the paucity may be the focus of research in
the late 1970's was on process rather than structure of
prenatal care in the health care system (Levine et al., 1978;
Wirth et al., 1977). The primary APN utilized in the late
1970's and early 1980's for prenatal care was the certified
nurse midwife with research more focused on comparison of
services to the physician for low risk populations. Five

studies are reviewed which focus on APN utilization.

26

Saba and Louis (1996) surveyed physicians (ns211), APNs
(np76), and nurse administrators (n-44) in Nevada about their
willingness to hire APNs. The study measured willingness to
hire, not actual numbers of APNs currently employed. The
data was compared to 1990 data. There was an increase in all
three categories of health care professionals in their
willingness to hire APNs. The family APN was the most
desired and needed specialty over all types of APNs and
chosen by all three health care professional groups as their
first or second choice for willingness to hire and need to
hire APNs. A limitation of this study is lack of
generalizability because the sample population was limited to
one state.

A study of large health systems (n=26) across the U.S.
were surveyed by phone to explore the utilization of the APN
(Schaffner et al., 1995). These phone interviews were done
with a Vice President of Nursing in the hospital associated
with a clinic or series of clinics. The second phone survey
was with a physician administrator in the clinics associated
with the hospital. Although this study was across 13 states,
there was no separation between rural and urban. The study
referred to data about the increasing amount of primary care
being provided by APNs, although no data was provided to
support this statement. Eighty percent (n=21) of the health
systems interviewed were utilizing APNs in the clinics.
Approximately 16% (n=4) of the systems reported an increased
use of APNs for rural primary care. All systems surveyed
were expanding the roles of the APN to be better utilized.

27

This study indicated utilization of the APN across 13 states
is increasing and will continue to increase based on the
types of insurance (managed care), knowledge, and experience
with the APN as a provider.
Morgan (1993) set out to determine how many states

distinguish and count nurse practitioners in each state.
This data has substantial value since no other information of
this data has been brought together in recent literature. A
phone survey was conducted with state boards of nursing
across the United States. Specific questions about RNs in
general, certification requirements, the number of nationally
certified APNs and the number of APNs in the state. Survey
findings indicate only slightly more than 1% of the licensed
RNs in 34 states were APNs. It should be noted 16 states do
not distinguish between APNs and RNs in their state.
Interestingly, the survey results showed that the Southwest
and Western regions had between one and three percent
licensed APNs and the Mid-west and Southern regions had less
than one percent licensed APNs. A

An early study giving the historical perspective of work
done analyzing the role of the APN in primary care (Levine et
al., 1978) looked at the perceptions of both the APN (n=58)
and the physicians (n=46) working with the APN of how well
tasks were completed. The information gathered included
demographics of types of patients seen by the APN and primary
reason for patient visits to the APN. No information was
provided about actual utilization or location of APNs.
Reasons for employing (utilization) were given. Twenty-three

28

 

El i7“.m' (

percent (np11) of physicians reported the number one reason
for adding an APN was the practice population had grown to
the point of needing another practitioner.

Sekscenski (1994) did a nation wide study looking at the
supply of APNs and practice environments. Of areas with
provider shortages, 75% (n=13 of 17 states) were rural,
however, no definition was given for "rural". The
information gathered included estimated number of
practitioners-to-population ratio for each state and national
mean. The conclusions identified a significantly higher
number of practitioners to populations ratio with positive
practice environments. Positive environments were described
as practices where APNs have greater autonomy through legal
status, reimbursement, and prescriptive authority.

~09 .0. Lo . e. e‘: - . .go . - e. e ;'(:

The most relevant study was a comparative study of
rural/urban non-physician providers in community and migrant
health centers (C/MHCs) (Shi et al., 1994). A survey (nF243
rural and n=140 urban) of clinic administrators was sent and
covered issues about current staffing average length of
employment of non-physician providers, 3-year projection of
staffing needs, training experience with non-physician
providers, and the region where the C/MHCs were located. The
results of this survey reported fewer APNs in rural settings
due to smaller number of providers needed compared to the
urban settings. Some interesting statistics reported in this
study were the percent of centers affiliated with training
programs for APNs at 37%, the percent of centers "interested”

29

in participating in training APNs was 71%, and the percent of
centers currently supervising student NPs was 32%. The
centers actually participating in programs either through
training or supervising, in other words utilizing APNs, were
similar, whereas, the percent of interested centers, but not
utilizing APNs, was doubled compared to the participating
groups.

There were empirical data in this study on numbers of
APNs currently employed in C/MHCs. An average of 1.0 APN was
employed in rural C/MHCs with 2 APN vacancies per community.
Advanced practice nurses were more likely to be employed in
the South and West in this study. These findings were
similar in another study (Morgan, 1993) for the West, but not
for the South.

In summary, the literature reviewed found general
support for the APN (Sabo & Louis, 1996; Schaffner et al.,
1995; Shi et al., 1994). Information about geographic
location and utilization of the APN indicates greater
utilization in the West by both sources (Morgan, 1993; Shi et
al., 1994) and in the South (Shi et al., 1994). The APN is
not utilized as much in the Mid-West and North-East (Morgan,
1993; Shi et al., 1994). The literature reviewed overall,
was consistent in the acceptance and utilization of the APN
from a small sample perspective in individual specialty
groups to the diversity of CHCs across the Us both urban and
rural. One of the most consistent factors throughout was the
literature was the future utilization and indications of
utilization. The APN was noted in several studies (Sabo &

'30

 

Louis, 1996; Schaffner et al., 1995; Sekscenski, 1994; Shi et
al., 1994) to be expanding roles and increasing numbers.
Wen

Critique of the literature demonstrates some empirical
work has been done on utilization of the APN, with only three
studies reporting the importance of geographic location in
relationship to actual utilization of the APN (Goldberg et
al., 1984; Shi et al., 1994; Wirth et al., 1977). The
majority of the studies analyzed others' perceptions of how
well the APN performs tasks (Levine, 1978), descriptive
information about potential utilization of the APN (Morgan,
1993; Sabo 8 Louis, 1996; Schaffner, 1995), and factors or
environments which affect the APN's ability to practice
(Sekscenski, 1994).

Two major limitations of the utilization studies were
the small samples and the dated studies (Goldberg et al.,
1984; Levine et al., 1978; Sabo 8 Louis, 1996; Wirth et al.,
1978). Only three studies included national information
limiting the generalizability of the work done (Schaffner et
al., 1995; Sekscenski, 1994; Shi et al., 1994). Many of the
utilization studies were done with one specialty group or a
small sample of limited population, without the specification
of rural or urban areas (Sabo 8 Louis, 1996; Wirth et al.,
1977).

An important consideration when reviewing and
interpreting rural health research is how rural health has
been defined. Each rural community has unique features that
determine the areas of health care needs, therefore, it is

31

 

not appropriate to generalize that all rural areas have the
same needs across the United States (Farmer et al.,1993).
The use of non-metropolitan areas compared to metropolitan
areas is too broad and does not capture the essence or
characteristics that make rural populations throughout the
United States vulnerable (Edelman 8 Menz, 1996; Rivo 8
Satcher, 1993; Sekscenski, 1996). The true needs of
populations with limited access to care could be more
effectively and accurately measured with more focused studies
on similar rural populations, and/or more specific breakdowns
of rural populations into smaller and more categories (Brown
8 Grimes, 1995; Sekscenski, 1996; Schaffner, 1995; Shi et
al., 1994). The need for additional studies is clearly seen.
This study, hopefully, will provide additional information
about utilization of the APN in rural CHCs across the United
States by region.
Method

W

This study used a descriptive approach using data from
the study ”Provisions of Prenatal Care by Rural CHCs in the
United States" (Omar et al., 1997). The primary study used a
survey to describe the provision of prenatal care in rural
CHCs in the U.S. Field procedures for the primary study are
in Appendix A.
annals

Surveys were originally sent to the 352 rural CHCs in
the U.S. The primary sample consisted of 162 surveys
completed by executive directors of rural CHCs, resulting in

32

a 46% response rate. The final sample for this study
consisted of 112 surveys for which there was complete data
from rural CHCs which provided prenatal care services within
the contiguous U.S. Exclusion criteria were states outside
of the contiguous U.S. and U.S. territories (Hawaii, Alaska,
Guam, Dominican Republic, and Puerto Rico), and those CHCs
that did not provide prenatal care.
QueratinnaLDefinifinnJanriables

Utilizatign_gf_thg_A£n was operationally defined as the
current employment of the APN as identified in Item 2 of the
Partnership for Rural Prenatal Care Delivery Survey. The
respondent were asked: "Are Advanced Nurse Practitioners
(i.e., Certified Adult Nurse Practitioners, Certified Nurse
Midwives, Family Nurse Practitioners, Pediatric Nurse
Practitioners, Women's Health Practitioners) currently or in
the last year employed at your CHC?" The choices for
answering this question were (1) Yes or (2) No. Answering
"Yes” to this question indicated utilization of the APN.

WC was Operationally
defined as the region based on the state in which the CHC was
located. The four regions of the U.S. were defined by the
U.S. Census Bureau (Figure 1). The four regions were West,
Mid-West, South and North-East.
Wanna

There was one main instrument in the primary study which
was developed by the primary investigators. The Partnership
in Rural Prenatal Care Delivery Survey is a 14 item self -
report survey with forced choice responses (see Appendix B).

33

The survey allows the respondent to provide information about
the provision of prenatal care, type of providers who deliver
prenatal care, types of providers who deliver infants, and
willingness to use APNs in the provision of prenatal care
delivery. There was no reported reliability or validity of
the survey used in the primary study.
Data_Anal¥ais

Data analysis was done using SPSS/PCT computer program.
Descriptive statistics were used to present characteristics
of the rural CHCs. To answer the research question, a
contingency table was constructed in which frequencies of the
two study variables, utilization of the APN and geographic
location of the rural CHCs were cross tabulated. To answer
the hypothesis, the chi-square test was used. A significance
level of 0.05 was used.
AW

Assumptions of the study were that the responses to the
questionnaire reflect honestly and accurately the rural CHCs'
practices and protocols. It was assumed that all data were
entered accurately.
Wrist

Limitations of the study include the following possible
response bias. The primary data gathered was for rural CHCs
providing prenatal care, this may have eliminated rural CHCs
from the study that did not provide prenatal care but did
utilize APNs. The use of a mailed survey yields a lower

return rate limiting the sample size.

34

W

The primary study used voluntary respondents who
completed the mailed survey. Approval to conduct a secondary
analysis was obtained from the University Committee on
Research Involving Human Subjects (Appendix C). No
potentially dangerous or adverse effects to the participants
was known or identified. The primary study (Omar et al.,
1997) was approved by Michigan State University Committee on
Research Involving Human Subjects (Appendix D). The data
utilized for this study has been maintained on a disk by the
investigator. The respondents were entered by identification
number only and did not reveal any subject identity. Thus,
no link can be made with the name or site of any respondent
for this study.

Results

DessrintinnJLSamnle

There were 112 executive directors who responded to the
survey. This study's sample size was smaller than the
primary study for data analysis purposes, because data
analysis was done only on cases which had complete data for
the variables under study. The number of prenatal care users
in the rural CHCs ranged from 0 to 3520 with a mean of 319
(SD=483.5). The range of APNs that could or are providing
prenatal care was 0.65 to 20 with a mean of 3.35 (SD=3.1).
Generally, the rural CHCs' prenatal users' payment sources
were a mixture of all three, no insurance, Medicaid
insurance, and a combination of public and private insurance.
Table 1 summarizes the characteristics of this sample.

35

Table 1.

WWW:
W

 

 

Characteristic n(missing) M SD Min. Max
No. of prenatal care users 88(24) 318.6 483.5 0 3520
No. of APN prenatal care
providers 78(34) 3.35 3.1 0.65 19.70
Payment source
No Insurance 80(32) 3237 3102 1 14279
Medicaid 52(60) 3077 2861 47 15930
Public and Private 50(62) 2898 3471 19 15632

 

The locations of the rural CHCs used in this study that
provided prenatal care are summarized by region. In the
Western region, eight (72%) of the 11 states had rural CHCs.
In the Mid-western region, eight (67%) of the 12 states had
rural CHCs. Thirteen (81%) of the 16 states within the
Southern region had rural CHCs and in the North—Eastern
region, six (67%) of the nine states had rural CHCs. The
total number of states represented in this study was 35 of
the 48 continental states, or 73%.
AnalxsiuLRessamhMesfion

Bgsgazgh_9ne§tign: Are there proportional differences
between geographic location of rural community health centers
and utilization of the advanced practice nurse?

A Cross-tabulation between geographic location of rural
CHCs and utilization of the APN was completed (see Table 2).
No association was found between the two study variables.

The Western region employed the largest percent of APNs, 86%

36

Table 2.

 

 

Geographic Location
West Mid-west South North-East
Employment of APN n % n % n % n %
Yes 25 86 21 84 34 79 ll 73
No 4 l4 4 16 9 21 4 27

 

(n325), followed closely by the Mid-Western region 84%,
(n=21); 79% (n=24) of the rural CHCs in the Southern region
employed APNs and 73% (n=11) of the APNs in the North-Eastern
region were employed in rural CHCs. Overall, 81% of the
rural CHCs that provide prenatal care in the United States,

employed APNs within the past year.
HYDQIhGSiS

There will be a difference in utilization of the APN as
a health care provider in rural CHCs by geographic location.
There was no statistically significant difference found
between geographic location of rural CHCs and utilization of
the APN as a health care provider, x2 (3, n=112) = 1.343,
92.719.

Discussion

Samnls

The main finding from this study was that advanced

practice nurses were greatly utilized in the rural CHCs

37

surveyed. Eighty-one percent of executive directors (ns112)
reported that their rural CHCs employed APNs. These findings
are positive for the nursing profession and indicate
utilization of the APN, consistent with the literature (Sabo
8 Louis, 1996; Schaffner et al., 1995; Sekscenski et al.,
1994; Shi et al., 1994). The APN is becoming a major
component in primary health care. It can reasonably be
expected that the APN is considered a valued member of the
health care team offering expertise of information and
skills, participation in management of clients, and working
collaboratively with other members of the health care team.
The APN, as an expert in holistic and wellness oriented
health care, is an excellent solution to the gaps in the
health care system where people are without access to health
care, especially rural areas. As an independent practitioner
and collaborator, the APN is able to extend services
available to rural clients, thus, increasing the number of
available health care providers in rural areas. Prescriptive
privileges of the APN also provides increased access to
health care. With the increased utilization of APNs, the
medically underserved populations in the rural CHCs may have
their health care needs met more regularly. Advanced
practice nurses' willingness to practice in rural areas is
well documented (Buppert, 1995; Inglis 8 Kjervik, 1993). The
use of APNs as prenatal care providers must also be
encouraged.

While it was found that rural CHCs in the four
geographic regions of the United States employed APNs, there

38

were no statistically significant differences found by
geographic location. This finding needs further exploration
since differences were noted amongst the four geographic
regions with respect to access to primary health care,
primary care physicians, and physicians providing prenatal
care, as well as health care coverage and poverty status.
Health status of the populations throughout the four regions
is varied and unique, but with a common thread of gaps in
health care that the APN can fill. Similarities can be made
among the four geographic regions employing APNs. The four
geographic regions were similar with respect to age of the
populations. As discussed earlier, the need for prenatal and
primary care providers, care of the uninsured populations,
and areas of the country with access to health care issues
show the greatest need and crosses all regions of the nation.
Perhaps the need for the APN in providing rural health care
services outweighs the differences of geographic location
offering an explanation for the high utilization of APNs
found in this study. I 4

Some limitations to the study's findings include a small
sample size which resulted from using a mailed survey. While
it was a smaller sample, it can still be considered
representative of those rural CHCs that provide prenatal
care. Consideration of the non-responders to the survey is
important. Non-responders may have been a) smaller rural
CHCs that did not employ APNs, b) unable to answer the
survey, or c) non-providers of prenatal care. The results of
this study may not have changed even with the additional

39

responses. Therefore, increased credence can be given to the
findings of the study.
Wham

The results of this study support the adaptation of
Starfield's (1992) Health Services System. Under the
structural component, personnel, there was support for the
APN utilized as a health care provider, with more than four-
fifths of the rural CHCs in this study employing APNs. This
provides support for the APN as part of the structure in
health care delivery in rural CHCs.

Geographic location corresponded to the social and
physical environment component of the model. Rural CHCs
throughout the nation were represented in the sample. While
no differences were detected in rural CHCs, this may be due
to the similarities of the social and physical environment of
rural CHCs rather than differences by geographic location.
Comparison by geographic location between urban and rural
CHCs might provide additional insight as to the nature of the
social and physical component of the model. This study did
not address the process or outcome components. There is
initial support for this model and is effective for
evaluating APN utilization in health care delivery.

... - H: . H .. -. - . ' - ( -.. .,. - ... . ;

Although the results of this study revealed no
statistically significant difference between the geographic
regions of rural CHCs and utilization of the APN, findings
from this study indicate the APN is being utilized in the
majority of the rural CHCs.

4O

Rural CHCs are the health care providers for the
medically underserved. Positive perceptions of the APN as a
health care provider to the medically underserved will impact
the utilization of the APN in rural settings. Utilization of
the APN in rural CHCs provides the opportunity for the APN to
be a role model. The APN can actively demonstrate
capabilities through the advanced knowledge and skills,
services being provided in the rural CHCs, and accountability
to clients and colleagues for actions in health care
delivery. While this study did not look at urban areas,
private practices, hospitals, or other areas of health care
utilization of the APN, the APNs providing care in rural CHCs
can be leaders and role models for the utilization of APNs in
all areas of health care delivery.

In those rural areas not utilizing the APN, the APN can
educate the executive directors, staff, and the general
public as to the scope of practice, skill level, and role in
the health care team. This could be achieved through
inservices for administrative and health care staff,
participating in or volunteering in community health
activities, e.g., conducting high school and college sports
physicals, guest speaking at various community groups to
increase awareness and value of the APN in the delivery of
health care to the community.
W

The APN must continue to use scientific investigation to
advance the profession of nursing and advanced practice.
Further replication of this research study with greater

41

emphasis on increasing the response rate is needed to further
test the research question and hypothesis. Additional areas
to research include further study using the conceptual frame
work. Other aspects of the model using APNs can be studied,
such as process and outcomes components. The APN has been
shown to be a component of the health care system structure
in this study. Characteristics of the patient population is
another area to study which may reflect differences in the
utilization of APNs.

The literature was very limited in the utilization of
the APN by geographic location and needs to be researched
further in future work. Further research of the geographic
location can be done, comparing other social and physical
environments, such as urban CHCs and other health care
delivery systems, e.g., private practices, acute care
settings, and managed care organizations. Cost effectiveness
and outcomes of health care managed by the APN by geographic
location could also be very beneficial to the health care at
large. A .

Summary

This study examined if there was a difference between
the utilization of the APN by geographic location of rural
CHCs providing prenatal care. Although the findings in this
study did not support a difference by geographic location, it
did offer enlightening information about utilization of the
APN. The APN was utilized in the majority of rural CHCs in
this study sample. Advanced practice nurses as a profession
need to educate and demonstrate to the medical community and

42

consumers about the role of the APN. There still exists some
who are unaware of the APN role and credibility as a health
care provider. With increased acceptance and utilization of
the APN, gaps in health care can potentially be reduced and

better health outcomes achieved throughout the United States.

43

LIST OF REFERENCES

LIST OF REFERENCES

Aaronson, L.S. (1987). Nurse-Midwives and
Obstetricians: Alternative models of care and client "fit”.

Research_in_Nursinc_8_Health1_in, 217-226.

Anderson, A.L., Gilliss, C. L., 8 Yoder, L. (1996).
Practice environment for nurse practitioners in California,

Identifying barriers. WWW“) .
209-14.

Bamberg, R., Malvey, D., Wainright, M.C., Fottler, M.D.,
8 Joiner, C.L. (1994). The development of a state-level
health manpower database using an employer-based survey: A

Pilot PrOject- The_JQurnal_9f_Bural_Health1_ln(3). 199-207-

Bigbee, J.L. (1992). Frontier areas: Opportunities for

NPs' primary care services. Nurse_2ragtitignez+_11(9), 47-
57.

Brown, S.A. 8 Grimes, D.E. (1995). A meta-analysis of
nurse practitioners and nurse midwives in primary care.

Nursins_Besearsh1_44(6), 332-9.

Buppert, C. K. (1995). Justifying nurse practitioner

existence: Hard facts to hard figures. Nu:§g_zzagtitigngz
20(8), 43- 8.

Bureau of Primary Health Care. (1996). Community Health
Center program [on-line]. Available:
http://www.bphc.hrsa.dhhs.gov/chc/chcl_1.htm

Conway-Welch, C. (1991). Supplemental issues
surrounding the distribution and utilization of nurse
nonphysician providers in rural America. The_1gnnna1_gfi

Rural_Health1_1(4). 388-401-

Edelman, M.A., 8 Menz, B.L. (1996). Selected
comparisons and implications of a national rural and urban
survey on health access, demographics, and policy issues.

The_Jnurnal_nf_8ural_Health1_12(3). 197-205-

Encarta 96 Encyclopedia [Computer software]. (1996).
Microsoft Corporation. Funk 8 Wagnalls Corporation.

Farmer, F.L., Clarke, L.L., 8 Miller, M.K. (1993).
Consequences of differential residence designations for rural
health policy research: The case of infant mortality. The

Journal_9f_Eural_Health1_2(1), 17-26.

Goldberg, H., Hafferty, F., 8 Fowkes, V.K. (1984). The
effect of decentralized education versus increased supply on

practice location. Mediga1_garg+_zz(8), 760-69.
44

Goldsmith, H.F., Puskin, D.S., 8 Stiles 0.8. (1993).
Improving the operational definition of “rural areas" for
federal programs.
http://www.nalusda.gov/ric/richs/goldsmit.htm

Inglis, A.I. 8 Kjervik, D. (1993). Empowerment of
advanced practice nurses: Regulation reform needed to

increase access to care. WWW
WW). 193-205.

Kohler, P. O. (1994). Specialists/primary care
professionals: Striking a balance. Ingni:y_11, 289-295.

Kohrs, F.P., 8 Mainous, A.G. (1996). Is health status
related to residence in medically underserved areas?
Evidence and implications for policy. Thg_19nznal_g£_nnzgl
Health1_12(3). 213‘224-

Kviz, F.J., Misener, T.R., 8 Vinson, N. (1983). Rural
health care consumers' perceptions of the nurse practitioner

role. WWW“) . 249-262-

Levine, J.I., Orr, S.T., Sheatsley, D.W., Lohr, J. A.,
8 Brodie, B.M. (1978). The Nurse Practitioner: Role,

physician utilization, patient acceptance. Nursing_3g§gangh+
2114), 245-54.

Lucas, C.A. 8 Rosenthal, T.C. (1992). Access to health
care in rural western New York State. ugw_xgrk_§tatg_lgnznal
9f_Medicine1_22(11). 465-468-

McClanahan, P. (1992). Improving access to and use of
prenatal care.

WW”) , 280-83.

McGrath, S. (1990). The cost-effectiveness of nurse
Practitioners. WWW). 40- 2-

Morgan, W. A. (1993). Using state board of nursing data
to estimate the number of nurse practitioners in the United

States. Will”. 69- 73-

Morgan, K. 0., Morgan, 8., 8 Uhlig, M. A. (1998). Health
(6th ed.). Kansas: Morgan Quitno.

Office of Technology Assessment. (1990). Health care in
rural America. OTA Publication No. OTA-H-434. Washington,
DC: Government Printing Office, 237.

Office of Technology Assessment. (1990). Nurse
Practitioners, Physicians Assistants, and Certified Nurse
Mid-Wives: A policy analysis. HCS 37. Washington, DC:
Government Printing Office.

45

Fumlxm'tn “-1an

Ohliger, J. (1985). Factors related to women's
preferences for OBGYN care providers: an explanatory survey.

Healfh_Care_for_anen_Internatinnall_6 327-40.

Omar, M., Schiffman, R., 8 Hogan, A. (1997). Provisions
of prenatal care by rural CHCs in the United States.

Pearson, L.J. (1997). Annual update of how each state
stands on legislative issues affecting advanced nursing

practice. Ths_Nurse_2racfitioner1_22(1). 18-35-

Ricketts, T.C. (1992). Education of Physician
Assistants, Nurse Midwives, and Nurse Practitioners for rural

Practice. Journal_of_8ural_nealth.

Rivo, M.L., 8 Satcher, D. (1993). Improving access to
health care through physician workforce reform. JAMAI
210(9), 1074-1078.

Sabo, C.E., 8 Louis, M. (1996). Nurse Practitioners:
Reevaluation of the need for and willingness to hire by
nursing administrators, nurse practitioners, and physicians.

(8).
375-31.

Schaffner, J.W., Ludwig-Beymer, P., 8 Wiggins, J.
(1995). Utilization of Advanced Practice Nurses in
healthcare systems and multispecialty group practice. IQNAI
25(12), 37-43.

Schleuning, D., Rice, 6., 8 Rosenblatt, R.A. (1991).
Addressing barriers to perinatal care: A case of the access
to maternity care committee in Washington state. Euhllg

Hfifllih_R§RQIL§+_lQ§(l), 47-52.

Sekscenski, E.S., Sansom, S., Bazell, C., Salmon, M.E.,
8 Mullen, F. (1994). State practice environments and the
supply of physician assistants, nurse practitioners and
certified nurse midwives.
111(19), 1266-71.

Shi, L., Samuels, M. E., Ricketts, T. C., 8 Konrad, T. R.
(1994). A rural-urban comparative study of nonphysician
providers in community and migrant health centers. Public

Health_Rencrtsl_192(6). 809 815-
Starfield, s. (1992). Primar¥_carei_Concent1

Towers, J. (1990). Report of the national survey of the
American Academy of Nurse Practitioners, part III. Comparison
of nurse practitioner characteristics according to education.

a. e a; ;u‘ .0 ; ;e‘u s Q‘ \ - . e.‘ :

2(3), 122-4.

46

U.S. Bureau of the Census (1997). Statlstigal_Ah§tzagt
gf_th§_nlsl (117th ed.). Washington, DC.

U.S. Census Bureau. (1996). [on-line] Available:
http://www.census.gov

Wirth, P., Kahn, L., 8 Storm, E. (1977). An analysis of
50 graduates of the Washington University Pediatric Nurse
Practitioner program. Part 2: Determinants of geographic
location. Nurse_2ractitioner. 14-17.

47

APPENDIX A

 

APPENDIX A

Field Procedure for the Primary study

The Partnership for Rural Prenatal Care Delivery Survey
was mailed to the executive directors of 352 rural Community
Health Centers. A cover letter explaining the study was
included with the survey. The letter requested that the
executive directors complete and return the survey in the
self addressed envelope within two weeks. Consent to
participate in the study was assumed when the survey was
completed and returned. A post card was sent two weeks after
the initial mailing as a reminder to complete and return the

survey.

48

 

APPENDIX B

 

RESEARCH
AND
GRADUATE
STUDIES

UdamMyhmmmuswi
Research ”I”

MUESNII
FAX' SIT/43241"

"submeIHthv
nashmuwwanuy
mum

I‘vsmahmmesta

   
 

MICHIGAN STATE

 

UNIVERSITY

May 11, 1999

To: Mildred A. Omar

A-230 Life Sciences

RE: IRBU:
TITLE :

REVISIW REQUESTED
CATEGORY:
APPROVAL DATE :

The University Committee

98-306 ‘

WHAT IS THE DIFFERENCE BETWEEN UTILIZATION OF
THE ADVANCED PRACTICE NURSE FOR PRENATAL CARE
AND THE GEOGRAPHIC LOCATION OF THE RURAL
$9:MUNITY HEALTH CENTERS

69707/90

on Research Involving Human Sub ects'IUCRIHS)

review of this project is gomplete. I am pleased to adv so that the
uman

rights and welfare of the

pgotected and methods to

sub acts a ar to be ade atel
obtain infgrmed cgg:ent are ap rggriatz.

erefore. the UCRIHS approved this project and any rev sions listed

VB.

0

RINIWAL: UCRIHS approval is valid for one calendar year, beginning with
o

the approval

date shown above. Investigators planning t
continue a pro

ject d one year must use the green renewal

form (enclosed with t e originaltagproval letter or when a
e

pro set is renewed) to seek u

certification. There is a

max mum of four such expedite renewals ssible. Investigators
wishing to continue a reject beyond tha time need to submit it
0

again

REVISIONS: UCRIHS must r

subjects, rior to in

r complete rev ew.

eview any changes in rocedures involving human
tiation of t e change. If this is gone at
o

the time o renewal, please use the green renewal form.
0

revise an ap
send your wr
approval and
in our reque

roved protocol at an her time during the year
tten request to the IHS Chair, requesting revised
referencin the project's IRB A and title. Include
st a descr ption of the change and any revised

ins ruments, consent forms or advertisements that are applicable.

Pnoansusl
CHANGES: Should either

work, investi ators must not
(unexpected s de effects

subjects or I

of the following arise during the course of the
i UCRIHS romptly: (1) roblems

comp aints, e c.) involving uman

2) changes in the research environment or new

information indicating greater risk to the human sub ects than

existed when

If we can be of any futu
at (517)355-2180 or FAX

13‘

d E. Wright, P
as. cram

Sincerely,

:bed

: Lisa K. Bigelow

the protocol was previously reviewed an approved.

re help please do not hesitate to contact us
(517I4 i- 171.

459

1,.

._ 2‘,
a 2:"—

APPENDIX C

 

amc£a=

 

IflmmmSquMmsn
ZBAammwalomwn
thmanflmmm
48824-1046

MUNSHHI

Flat 5171(32-1111

A611 IS an WWI-m
lemma-nay mm

MICHIGAN STATE

UNIVERSITY

 

March 1, 1995

TO: Mildred“
A230 Life Sciences Bldg.

RE: IRE}: _ 94-151
TITLE: BARRIERS, EXPECTATIONS, AND PATIENT SATISFACTION
AS PREDICTORS OF PRENATAL CARE UTILIZATION AND
MATERNAL AND INFANT OUTCOMES IN BENZIE COUNTY,

MICHIGAN
REVISION REQUESTED: N/A
CATEGORY I-C
APPROVAL DATE: 03/01/95

The University Committee on Research Involving Human Sub ects'(UCRIHS)
review of this project is complete. am pleased to advu em the
rights and welfare of the human subjects appeart to“ adequately
Med and methods to obtain informed» nsent are appropriate.
1heraflore, the UCRIHS approved this projtct including any revision
st above.

MINIMAL: UCRIHS approval is valid for one calendar you beginning with
the approval date shown above. Investigators planning to
continue a proj ject beyond one year must use the green renewal
form (enclosed with e originalta groval letter or whena

project is renewed) to seek u xcertification. There is a
max of four such expedi t renewals ssible. Investigagor:

wishin to continue a project beyond tha time need to s
again or complete rev

RIVISIOII: UCRIHS must review an chanw s uprocedures involving hm
subjects, rior to in tiation of t e change. If this is done at
the time o renewal, please use the green renewal form. To
revise an a roved protocol at an 0 her time during the year
send your wr tten request to the CRIHS Chair, requestingm mised
approval and referencing the project's IRB I and title. .Include

nyour request a descr ption of the change and anym
ins mats, consent forms or advertisements that are applicable.

PROBLEMS

CIAMCSS:’ Should either of the followin arise during the course of the
work, investi ators must noti UCRIHS .promptly: {g roblems
(unexpecteds sde effects comp aints, involv
subjects or Ina changes in the research environment or new
information icating greater risk to the human sub ects than
existed when the protocol was previously reviewed approved.

Ifm of any future help lease do not hesitate to contact us
at (517)355-2180 or FAX (517)3 &- 111.

Sincerely,

   

avid E. Wright, P
UCRIHS Chair

50

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