Despite the advantages of NPs in rural areas, barriers to practice remain.
Editor’s note: This article appeared in the July-September 2023 edition of HealthLeaders magazine.
With more than 100 million Americans lacking access to primary care, employing more nurse practitioners (NPs) and allowing them to practice at the top of their license is critical to making healthcare more accessible in rural areas, NP leaders say.
NPs could ease "care deserts" created by physician shortages and rural hospital closings. Nearly 80% of rural U.S. counties are medical deserts, according to the NRHA. About 35% of all U.S. counties are "total maternity deserts"—no access to prenatal or delivery services—and another 54% are considered partial deserts, which equates to 7 million women without access to maternity care, according to the March of Dimes.
"There are many people who don't see a doctor or get healthcare on a regular basis, and when they are really sick, they go to the emergency room for their care," says April Kapu, DNP, APRN, ACNP-BC, FAANP, FCCM, FAAN, immediate past president of the American Association of Nurse Practitioners (AANP).
"It is definitely a need in rural health that we get providers out in every community," Kapu says.
Growing in number
The demand for NPs is growing and their role is expanding, thanks in part to an aging U.S. population, increasing infectious diseases, rising chronic diseases, and fewer physicians, the AANP says.
The percentage of rural physicians has declined—12.8% from 2008 to 2016. But the percentage of NPs increased 17.6% during that same time period, according to a 2020 study.
"We're growing at a rate of about 9% a year," Kapu says. "We are up to more than 355,000 nurse practitioners across the U.S. today, and we are estimated to grow by 46% by the year 2031."
Nearly 90% of NPs are certified in an area of primary care and 70.3% of all NPs deliver primary care, according to the AANP, with 83.2% of full-time NPs seeing Medicare patients and 82% seeing Medicaid patients. Additionally, nearly half of all rural primary care practices have at least one NP, according to the NRHA.
A well-rounded approach to healthcare
NPs' holistic, wellness-centered approach to primary healthcare—health promotion, prevention, and chronic disease management—is particularly beneficial to rural patients who must travel long distances when illness requires acute care.
"One really valuable thing they bring to rural health is the approach to healthcare, which differs a bit from the medical model," says Michele Reisinger, DNP, APRN, FNPC, a working NP and assistant professor of doctoral nursing at Washburn University in Topeka, Kansas. "Nurse practitioners are trained to look comprehensively at the individual."
NPs are well positioned for primary care roles because of their education and training, says Reisinger, who has helped obtain an advanced educational nursing workforce grant centered on educating nurse practitioners for rural practice.
"When we train them as nurse practitioners, we train them to manage chronic disease states; we train them to be experts in promoting health and wellness [as opposed] to an urban setting where they may work only in urgent care … or have a very targeted education in cardiology or neurology," Reisinger says.
Instead, rural nurses treat the spectrum of pregnant women, infants, children, adults, and geriatric patients, along with entire families, she says.
"Nurse practitioners in rural areas wear many hats," she says. "They may be seeing primary care patients; they may be tasked with extended care rounds in nursing home facilities, which requires extensive geriatric management; or they may be in a setting that requires knowledge of trauma. So, we try to prepare them in a way that is global in that manner."
Working closely with patients allows NPs to create collaborative prevention plans to help patients make lifestyle changes and health choices that can stave off chronic disease and keep them out of the emergency department, Kapu says.
"We know that timely access to care, particularly preventative care, is crucial to the early detection of health issues," Kapu says. "It has a huge impact on the mitigation of healthcare cost, and so important to health and well-being overall, and whenever that care is delayed, we know that individuals face a greater risk for complications for not following up on chronic diseases."
Such preventive care makes a difference to rural patients, Kapu says. "Many large-scale reliable studies have shown that we have a tremendous impact on the reduction of unnecessary emergency department visits," she says.
Breaking down barriers
Despite the advantages that NPs can bring to rural, underserved areas, barriers continue to limit them from working at the top of their license, Kapu says.
For example, even though more than half of U.S. states have granted NPs full practice authority (FPA)—which allows them to evaluate and diagnose patients, order and interpret diagnostic tests, and initiate and manage treatments under the exclusive licensure authority of the state board of nursing—nearly as many states make it illegal for NPs to practice their profession without a collaborative agreement with a physician.
The American Medical Association (AMA) and other physician groups accuse FPA of "scope creep" and charge that nonphysicians practicing medicine is a threat to patient safety. At its annual meeting in June, the AMA passed a policy amendment calling for advanced practice RNs (APRN) to be licensed and regulated jointly by the state medical and nursing boards. Nursing groups denounced the policy amendment.
States that have embraced FPA have increased their nursing workforce and helped ease care deserts, Kapu says. When Arizona enacted FPA in 2001, the NP workforce doubled across that state within five years and grew by 70% in rural areas, and North Dakota's adoption in 2011 saw its nursing workforce grow by 83% within six years, she says.
Some barriers are being reconsidered. The Improving Care and Access to Nurses Act (ICAN) was reintroduced in the U.S. Senate in April and would allow NPs, physician assistants, and other APRNs to provide particular services under Medicare and Medicaid. ICAN would, among other things, authorize NPs to order and supervise cardiac and pulmonary rehabilitation, certify when patients with diabetes need therapeutic shoes, and certify and recertify a patient's terminal illness for hospice eligibility.
"These are substantial barriers that, if they were removed," Kapu says, "we will be able to provide much-needed, timely care, and [for] our elderly and Medicare beneficiaries who live in these rural communities."
“One really valuable thing [NPs] bring to rural health is the approach to healthcare, which differs a bit from the medical model. Nurse practitioners are trained to look comprehensively at the individual.”
— Michele Reisinger, DNP, APRN, FNP-C, assistant professor of doctoral nursing, Washburn University
Carol Davis is the Nursing Editor at HealthLeaders, an HCPro brand.
From 2008 to 2016, the percentage of rural physicians declined 12.8% while NPs increased 17.6%.
NPs are well positioned for primary care roles because of their education and training.
Despite the advantages that NPs can bring to rural areas, barriers continue to limit them from working to the top of their license.