CLRPPT

 Key search words: Rural health, nurse practitioner, primary
care, and research.
 Inclusion criteria:
◦ Articles between 2007 and 2012
◦ Written in English
◦ Full text
◦ Qualitative and/or quantitative

 Database search:
◦ CINAHL Plus
◦ PubMed Central

 Ten studies that met inclusion criteria were chosen for review.

 4 articles were quantitative
 5 articles were qualitative
 1 article was mixed ( quantitative & qualitative)
 3 articles obtained informed consent
 5 articles documented IRB approval

Source Purpose/
Problem
Sample Concepts Design Instrument Results Implication Comments
Ortiz,
Wan,
Meemon,
Paek, &
Agiro
(2010)
Examine
relative
contribution
s of NPs to
rural health
clinics
productivity,
determine
the inter-
relationships
of efficiency
indicators &
identify
contextual
& structural
factors that
influence
the variation
in efficiency
Random NP
productivity
in RHC
Empirical,
quantitative
AMOS 7 NP FTEs
contribute
positively to
technical &
process
efficiency.
RHC that
utilize NPs
are more
cost
effective
Number of
NP FTEs is
a positive
factor on
technical &
process
efficiency
but does not
influence
cost
efficiency
Tables were
used,
limitations
listed, future
research
needed, no
informed or
IRB
approval
documented

Source Purpose/
Problem
Hanrahan &
Hartley
(2008)
Limited
access to
mental
health
services
Convenienc
e
Rural
Distribution
of APPNs
Quantitative Use state
fact sheet &
American
Nurses
Credentialin
g Center.
No
instrumentat
ion
documented
Ratio of
APPNs to
rural
population
ranged from
.06 to 14.9,
with a SD
ratio of
APPNs per
100,000 in
rural
population
was 3.0 ±
3.0
APPNs can
be the
solution to
the rural
mental
health
shortage
No
limitations,
no tables, no
informed
consent.
Exempt
from IRB
approval

Source Purpose/
Problem
Andrus &
Clark
(2007)
Clinical
pharmacy
intervention
and services
in
collaboratio
n with a NP
in a rural
health
center
Non-random NPs have
limited
training in
pharmacoth
erapy
management
& can
benefit from
a clinical
pharmacist
Retrospectiv
e chart
review,
quantitative
No
instrumentat
ion was
detailed
Improvemen
t in LDL,
systolic &
diastolic BP,
and HbA1c
showing a
direct
correlation
between the
collaborativ
e work of
the NP and
clinical
pharmacist
in rural
health
Larger study
needs to be
done
Tables were
used,
informed
consent not
documented,
approval
received but
not
documented
by whom, a
comparison
of patients
managed by
the
pharmacist
vs. a control
group
managed by
the NP

Source Purpose/
Problem
Everett,
Schumacher
Wright, &
Smith
(2009)
Identify
Characteristi
cs &
outcomes of
patients who
use NPs as a
usual source
of care
Convenienc
e
NP more
likely occur
in rural
areas
Quantitative
Telephone
& mail
surveys
Health
Utility Index
Summary
Score
(HUI3),
Group
Health
Association
of America
(GHAA),
Anderson
Model
Patients of
NPs are
rural,
usually
women,
more
women than
men
recognize
the NP as
their PCP,
men and
women
perceive
health care
outcomes of
the NP
similar to a
physician,
NPs are
improving
access by
serving the
rural
community
NPs are
improving
accessibility
to under-
Served
populations
such as rural
Results may
not easily
generalized
to other
populations.
Verification
of provider
type
lacking, no
informed
consent
documented,
IRB
approval
documented

Source Purpose/
Problem
Bowden,
Shaul, &
Bennett
(2007)
Counseling
intervention
s by NPs
Stratified
Random
Sampling
NPs can
Provide
support &
education
To
positively
Affect
change in
health risk
behaviors
Mixed,
Quantitative
&
qualitative
11 item
health status
profile for
quantitative,
for
qualitative
use of 6
open ended
questions,
written
notes taken
by research
asst., then
principal
investigator
& 4 member
research
team
identified
themes
NP had no
effect on
changing
health risk
behaviors.
Did affect
the need for
support &
education in
rural health
It may be
more
difficult for
a person to
change old
habits &
adopt new
health
behaviors in
the context
of rural
health
Documented
informed
consent &
IRB
approval, no
p values, no
CI, no tables

Source Purpose/
Problem
Conger &
Plager
(2008)
Scarcity of
health care
providers
leads to
reduced
access to
health care
in rural
residents
Convenienc
e
NPs in rural
health care
Qualitative Semi-
structured
individual &
focus group
interviews,
audiotaped
&
transcribed
verbatim &
reviewed for
accuracy, 2
independent
researchers
uncovered
themes &
validated
NP students
assigned to
rural health
clinics had a
positive
impact in
providing
care
NP students
who are
prepared in
rural theory
& have
practicums
in a rural
setting can
offer a
positive
impact in
rural health
care
Documented
informed
consent &
IRB
approval,
use of
tables, no
limitations
documented

Source Purpose/
Problem
Reay,
Patterson,
Halma, &
Steed
(2007)
Report of
experiences
of
introducing
a NP into a
rural
physicians
clinic
Snowball NP in rural
health care
Qualitative Open-ended
interviews 7
patient
survey &
billing and
work time
records.
Interviews
lasted 30-60
minutes
were
transcribed
& analyzed
using QSR-
N6 &
themes were
identified
High patient
satisfaction,
billing
potential
that
surpassed
salaries
NP can
enhance
physician
services in
rural clinic
and can be a
cost benefit
No informed
consent,
IRB
approval,
table used,
limitations
of small
sample size,
may not be
generalized

Source Purpose/
Problem
Roberts,
Johnson,
Brems, &
Warner
(2007)
To
determine if
providers
report
greater
difficulty in
providing
care for
rural
residents
and
minorities
Convenienc
e
NP
challenge in
rural health
care with
minorities
Qualitative 21 page
survey with
no emerging
themes
identified
and no
process of
verification
Rural NPs
identified
more
difficulty in
caring for
the minority
patient, but
the patients
felt the NP
took more
time with
them
Minority
patients in a
rural setting
may be
more likely
to receive
care that
does not
fulfill them
No informed
consent
documented,
IRB
approval
documented,
tables used

Source Purpose/
Problem
Gould,
Johnstone,
& Wasylkiw
(2007)
Investigate
the
experience
of NPs one
year after
working in
rural
Canada
Purposive NPs in rural
Canada
Qualitative Semi-
structured
interview,
questions
developed
by 3
researchers,
tape
recorded &
transcribed,
then
analyzed by
2
individuals
using the
methodolog
y described
by Attride-
Stirling
NP took
more time
with each
patient and
felt
education
was key
especially in
rural
communitie
s with a lack
of
intervention
s readily
available.
Felt
acceptance
by patients
due to
holistic
approach
Will high
levels of
patient
satisfaction
be
maintained
as practice
grows
No informed
consent or
IRB
documented,
table used

Source Purpose/
Problem
Higuchi,
Hagen,
Brown &
Zieber
(2007)
Role of the
GAPN in
rural
settings
Purposive NPs can
provide
enhanced
care to the
geriatric
population
in rural
health care
Qualitative Semi-
structured
interviews,
tape
recorded
lasting 45
minutes,
transcribed
& reviewed,
data
analyzed
using
qualitative
software
NUD*ST, a
coding
scheme was
developed,
independent
researchers
verified and
identified
themes
Improvemen
t in resident
care,
avoidance in
unneeded
admissions
to the
hospital
GAPN can
enhance
care in a
rural
enhanced
lodge
Documented
informed
consent &
approval by
2 research
ethics
boards, no
limitations,
limited
demographi
cs

 Unsuccessful Studies
◦ Roberts (2007), minority patients in a rural setting may be more
 Likely to receive care that does not fulfill their needs.
◦ Bowden (2007), the NP had no effect on changing health risk
 behaviors in the rural setting

 Successful Studies
 Ortiz (2010), rural health clinics that utilize an NP are more
◦ Cost effective
Hanrahan (2008), APPNs can be the solution to the rural
mental health shortage.
Andrus (2007), improvement in LDL, systolic & diastolic BP, and
HbA1c, showing a direct correlation between the collaborative
work of the NP & clinical pharmacist

 Successful Studies (cont.)
 Everett (2009), patients perceived the health care outcomes
◦ of the NP similar to a physician and NPs are improving
◦ Access by serving the rural community
Conger (2008), NP students assigned to rural health clinics
had a positive impact on providing care
Reay (2007), NP can enhance physician services in rural
clinic

 Successful Studies (cont.)
 Gould (2007), NP took more time with each patient and felt that
◦ Education was key, and NPs felt acceptance from patients due
◦ To holistic care
Higuchi (2007), NP was able to improve the resident care and avoid
unneeded admissions

 More research is needed to understand the impact that NPs can
have on serving in rural communities.
 Research needs to be easily generalized.

 Common themes did emerge from the literature that may help
answer the health care crisis in the rural communities.

 Andrus, M., & Clark, D., (2007). Provision of pharmacotherapy
◦ services in a rural nurse practitioner clinic. Journal of American
◦ Health System Pharmacy, 64 (2), 294-298.
Bowden, J., Shaul, M., & Bennett, J., (2007). The process of changing
health risk behaviors: An Oregon rural clinic experience. Journal of
The American Academy of Nurse Practitioners. 16 (9), 411-417.
Conger, M., & Plager, K. (2008). Advanced nursing practice in rural
areas: connectedness versus disconnectedness.

 Everett, C., Schumacher, J., Wright, A., & Smith, M. (2009). Physician
assistants and nurse practitioners as a usual source of care. Journal of
Rural Health, 25 (4), 407-417.
 Florell, M. (2009). Rural Health care workforce: Opportunities to improve
care delivery. Center of Rural Affairs, XX (6).
 Gould, O., Johnstone, D., & Wasylkiw, L. (2007). Nurse practitioners in
Canada: Beginnings, benefits, and barriers. Journal of the American
Academy of Nurse Practitioners, 19, 165-171.

 Hanrahan, N., & Hartley, D. (2008). Employment of advanced-practice
psychiatric nurses to stem rural mental health workforce shortages.
National Institutes of Health, 59 (1), 109-114.
 Higuchi, K., Hagen, B., Brown, S., & Zieber, M. (2007). A new role for
advanced practice nurses in Canada: Bridging the gap in health
services for rural older adults. Journal of Gerontological Nursing,
XX (X), 49-55.
 Ortiz, J., Wan, T., Meemon, N.,Paek, S., & Agiro, A. (2010). Contextual
correlates of rural health clinics’ efficiency: Analysis of nurse
practitioners’ contributions. Nursing Economics, 28 (4), 237-244.

 Reay, T., Patterson, E., Halma, L., & Steed, W. (2007). Introducing a nurse
practitioner: Experiences in a rural Alberta family practice clinic.
Society of Rural Physicians of Canada, 11 (2), 101-107.
 Roberts, L., Johnson, M., Brems, C., & Warner, T. (2007). Challenges
encountered by multidisciplinary providers in fulfilling ethical
standards in the care of rural and minority people. Journal of Rural
Health, 23, 89-97.

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