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RN-BSN Rural Nurse Initiative for Missouri
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RN-BSN Rural Nurse Initiative for Missouri


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  • 1. Improving Rural Health Outcomes: the innovative rural nurse education initiative JoAnn Klaassen, RN, MN, JD Clinical Assistant Professor Director, UMKC Rural Nurse Initiative ©Not for use without permission
  • 2. Focus on rural health
    • Rural health outcomes are universally worse than urban health outcomes
      • Higher MVA rate/MVA deaths
      • Higher smoking & substance abuse rates
      • Significantly higher male suicide rates
      • (Harkness & DeMarco, 2012; Rural Assistance Center, 2011)
      • Higher mortality rate for ages 1-24 (Bennett et al., 2008)
      • Less access to preventative/perinatal care
      • Higher rates of occupational injuries (Bushy, 2007)
      • Higher levels of non-insured, under-insured individuals
  • 3. Focus on rural health
    • Fewer resources available i.e. HPSA
    • Disproportionately Medicare/Medicaid funded
    • Community-based focus
    • Targeted for major changes via PPACA
    • Technology – tele-health in particular – seen as an emerging solution
    • Future funding and resource allocation are a concern
    • Regulatory burdens are disproportionate
  • 4. Rural Hospitals
    • Tremendous variability
    • Significant underfunding from Medicare (as compared to urban)
    • 470 hospital closures over past 25 yrs.
    • Some revitalization via CAH, block grants, etc.
    • Initially left out of health care law
    • Fewer physicians and specialists, shortage of nurses
    • Significant locus of control shift from community to federal/state govt
  • 5. Rural hospitals
    • Increasing pressure on rural hospitals struggling to comply with meaningful use, quality indicators and
    • Avalanche of new regulations
    • Potential negative impacts of ACOs
    • Under health care reform the potential for community-oriented care to be subsumed by large corporations
  • 6. Implications
    • Rural communities need visionary and innovative health care personnel
    • Every health care provider will need to operate at the “full extent of their scope of practice” (Wakefield, 2011)
    • Community collaboration is critical
    • Emphasis on aggregate and preventive care
    • Current information and appropriate educational levels/skill development are essential
  • 7. Rural nurse role
    • Perform as expert generalists
    • Function within the community culture
    • Rely on both formal and informal networks for health care services
    • Apply ethical principles in a cultural context (Bushy, 2009)
    • Independence, creativity, innovation required
    • Flat career ladder requires flexibility to incorporate non-traditional roles
  • 8. Rural nurses
    • More rural nurses with associate degrees which does not provide
      • Leadership skills, community/preventive health, mental health, policy development, etc.
    • Fewer opportunities to advance education i.e.
      • Travel to attend continuing education courses/conferences is a significant challenge (Mason, Leavitt & Chaffee, 2012)
    • Less exposure to emerging technologies but higher need
    • Rural nurses’ average age slightly higher than urban nurses -> older learners, higher learning curve
    • Often wear multiple hats in the health care setting – some for which they are not educationally prepared
    • Expectation for more complexity in role (Wakefield, 2011)
  • 9. Nursing Education
    • Majority of baccalaureate nursing programs are located in urban areas
    • Few incorporate rural health concepts
    • Rural nurses often feel disrespected by urban nurse educators
    • Studies confirm that rural nurses who leave for school often don’t return
    • Financial burden on rural nurses is higher
  • 10. Nursing Education
    • Access to and quality of on-line programs is an issue for rural nurses
      • Isolating, lack of support, irrelevant, repetitive
      • Preceptorships, residency, clinical require expense and travel
    • Nursing faculty are ill prepared to educate nurses about emerging technologies
    • Few programs offer authenticity for adult learners
  • 11. UMKC RN-BSN Program
    • On-line for the past six years
    • Traditionally urban focused
    • Uses an interactive approach (Wimba® Live Classroom) to connect cohort group members
    • A developmental framework based on Covey’s work – personal, interpersonal, human health outcomes, complex health systems
    • Multiple technology supports
    • Team-driven practicum
  • 12. The Rural Nurse Initiative
    • Designed to offer the same quality RN-BSN program to rural and remote practicing nurses
      • Outcome goals include networking rural nurses to urban resources such as simulation, EHR and other technologies
    • Rural health concepts are integrated into the curriculum
    • Broadband laptops provided to rural nurses and cost of service reimbursed
    • 24/7 live technology support and tutoring
    • Re-design of the practicum
    • Tele-health concepts drive a live on-line health assessment course
    • HRSA grant funded the program re-design and delivery
  • 13. Program success
    • Increase in rural nurses from approx. 10% to almost 50% of enrolled students
    • Overall enrollment increase from 40 students to 250+ students in 3 years
    • Almost 30% of rural graduates go on to advanced practice education
    • Identified by NLN as a ‘top 10’ nursing program for use of technology
    • HLC* 100% on-line certified – “a model program”
    • Student feedback is overwhelmingly positive
    • Students have extensive experience with a variety of technology applications including tele-health concepts
    • Enhanced respect for rural nurses
  • 14. Curriculum targeted to rural nurses
    • Curriculum re-designed to integrate rural health concepts into every course
      • Lecture/assignments
      • Faculty and guest experts
      • Discussion boards
      • Applied concepts
    • Content designed to compare and contrast urban and rural health issues
    • Increased focus on technology applications in health care
  • 15. Multi-modal technology supports
    • Broadband laptops for rural nurses
    • Blackboard® platform with Wimba® Live Classroom
    • Wikis
    • Wimba-based workrooms
    • File exchange
    • Instant messaging
    • Tutorials and orientation to the technology
    • 24/7 live technology support
  • 16. Virtual Practicum
    • Virtual practicum – encompasses 9 months across two courses utilizing virtual teams
    • Real projects in real communities – urban and rural
    • Every virtual team carefully combined with urban/rural and near/distance students
    • Utilization of the multi-modal technology to manage the virtual team project
    • Faculty work closely to set up projects and facilitate student groups in the ‘consultant’ role
    • Technology is used to connect community partners
  • 17.
    • Most projects have at least one student with ‘boots on the ground’
    • Student teams collaborate with a health agency to identify a need, assess the target population, develop a plan of action and implement strategies and/or products designed to improve health outcomes
    • Examples:
  • 18. Virtual Project
    • Research based
    • Collaborative
    • Virtual team driven
    • Attitudinal changes documented
  • 19. Student comments
    • “ Now I don’t want to let go [of the project]…”
    • “ I had worked on projects before – nothing to this extent. I gained so much out of it…”
    • “ I learned how to take an idea from paper and actually make it happen.”
    • “ I was able to see how an effective team really can work together to achieve a common goal.”
    • “ I am excited to be looking at the publication of our handbook – I would never have dreamed of this…”
    • “ I learned that nurses truly can make a difference in the lives of people and entire communities.”
  • 20. Live on-line health assessment
  • 21.
    • Traditional course – on-line instruction followed by 1 week of residency to practice and demonstrate skills
    • Learning Exchange Reverse Demonstration© - faculty developed model using best practices in skill demonstration coupled with tele-health techniques
      • Student groups meet 8 times/semester on-line to practice and demonstrate enhanced skill acquisition
      • No residency requirement
  • 22.
    • Model piloted for two semesters
      • Equal skill attainment with traditional course
      • More positive student comments for on-line instruction
      • Immediate instructor feedback and correction
      • Less cost and time commitment for students
      • More time and cost intensive for instructors
      • Prepares students to utilize tele-health constructs
      • Provides a method of broadly teaching a variety of skill acquisition and enhancement to remote learners
  • 23. Student supports
    • On-line site to access available supportive services
      • Student developed based on peer feedback
      • Counseling/stress management
      • Financial aid/management
      • Social network/family supports
      • Study/Academic
      • Link to SON social worker
    • Tutoring offered via desktop sharing (TeamViewer®)
  • 24.
    • Technology-supported peer mentoring
    • Faculty/Academic Advisor mentors for each student
    • 24-hour response rule for faculty
    • Engagement via multiple technologies
    • Rich media connectedness for all students
    • Group engagement via long-term virtual team practicum
  • 25. Faculty
    • All faculty are full-time, experienced on-line educators who have demonstrated excellence
    • All faculty committed to student success
    • Faculty are a combination of urban and rural practicing nurses
    • Faculty have acute and community-based care experience
    • Faculty live across the nation and model virtual teamwork and collaborative practice with emerging technologies
  • 26.
    • Faculty cohesion is valued
    • Students are treated as colleagues and diversity of gender, ethnicity, experience and viewpoint is valued and encouraged
    • Respect, responsibility, communication and excellence are the driving principles of the program
    • Reasonable flexibility coupled with high expectations
  • 27. How do we know it works?
    • Student/employer feedback
      • Relevance, role expansion, positive learning
    • Student learning outcome portfolios demonstrate relevant learning
    • Our students are the primary recruiting tool
    • Recognition from our professional organizations
    • Thirty percent of our students keep going!
    • Approximately 100 rural nurse graduates by December, 2011.
  • 28. Implications for rural health outcomes
    • Nurses understand and function in an expanded role
    • Collaborative, team-building and conflict resolution skills
    • Leadership principles and problem-solving
    • Every graduate is equipped to take a large-scale project from beginning to end
    • Graduates prepared for emerging technology use
  • 29.
    • Nurses understand principles of evidence-based practice and research fundamentals
    • Aggregate health assessment and intervention skills
    • Data gathering and analysis skills
    • Policy and protocol development skills
    • Increased awareness of emerging health issues and health care changes
  • 30.
    • New awareness of community-based health initiatives
    • Better understanding of continuum of care issues
    • Exposure to innovation and creativity in health care
  • 31. References
    • Bennett, K., Olatosi, B. & Probst, J.C. (2008). Health disparities: A rural-urban chartbook. South Carolina Rural Health Research Center, 4. Retrieved from:
    • Bushy, A. (2007). Rural Nursing: Practice and issues. ANA Continuing Education Program. Retrieved from
    • Bushy, A. (2009). A landscape view of life and healthcare, in rural settings in Handbook for rural health care ethics: A practical guide for professionals. Nelson, W. (Ed). Dartmouth College Press, N.H.
    • Harkness, G.A. & DeMarco, R.F. (2012). Community and public health nursing: Evidence for practice . Philadelphia, PA: Wolters Kluwer/Loppincott Williams & Wilkins.
    • Mason, D.J., Leavitt, J.K. & Chafee, M.W. (2012). Policy and politics in nursing and health care (6 th ed.). St. Louis, MO: Elsevier/Saunders.