The Last Ten Years: Nurse Practitioners in the Southern United States Employed in Medically Underserved Areas

Monday, 9 November 2015

Thomas Kippenbrock, MSN, EdD, RN
School of Nursing, University of Arkansas, Fayetteville, AR, USA
Wen-Juo Lo, PhD
University of Arkansas, Fayetteville, AR, USA
Ellen Odell, DNP, APRN
John Brown University, Siloam Springs, AR, USA
Bill Buron, PhD, APRN, FNP/GNP-BC
University of Arkansas for Medical Sciences, Fayetteville, AR, USA

Background & Significance: Collectively, the U.S. Southern states are some of the poorest, most rural, and socioeconomically deprived regions in the county.  Related to these conditions are the poor healthcare outcomes such as higher morbidities, shorter life spans, and higher death rates.  The South is home of many rural citizens and medically underserved areas.  Despite national databases affiliated with the Bureau of Labor Statistics and the Health Resources and Services Administration (HRSA), knowledge is limited regarding the nurse practitioner (NP) workforce in rural and medically underserved areas of the country. 

Purpose:  The aim of this research is to gain a better understanding of the characteristics of NPs working in the Southern U. S.  More specifically, the objectives are to examine and compare the demographic and descriptive characteristics (gender, race, income, practice specialty, and employer type) of NPs working in (a) health professional shortage areas (HPSA) versus non HPSA; and (b) rural versus urban areas during the past decade.

Method:  A non-experimental quantitative methodology employing three data collection sources was used in the study.  Over 1,500 NPs were surveyed both in 2000 and 2010 for demographics and descriptive information such as education, income, practice, employer, and workload.  Other data sources included Health Resources and Services Administration that identified HPSAs and the U.S. Census Bureau used to distinguish urban and rural employment settings.

Results:  The most dramatic shifts in NPs were older, more educated, and earned higher incomes; however, gender and race remained the same over the past decade.  Hospital employment was the largest increase and the greatest decline was private practice settings.  Family practice as a specialty increased slightly while no shift occurred in other specialties.  More NPs worked in HPSAs; however, rural located employment declined.  

Discussion: The findings of this study continue to suggest that NPs are an important workforce in the delivery of primary care services to rural and underserved populations of the Southern states, an area of the country associated with poor economic and health care outcomes.  NPs are employed in HPSAs and close to half work in the rural areas.  This workforce is consistent with NP history and traditional educational frameworks, focused on providing health care services to rural and underserved populations.

Conclusions: Despite three decades of attempting to diversify nursing student enrollment and increase the graduates of NP educational programs; racial diversity was almost non-existent within the NP population over the past decade.  The small minority of NP participants in this study is far below the number of Blacks and Hispanics living in the region as reported by the U.S. Census Bureau (Humos, Jones, & Ramirez, 2011; Rastogi, Johnson, Hoeffel, & Drewery, 2011; Ennis, Rios-Vargus, & Albert, 2011).  There is evidence that provider-patient race concordance improves not only patient satisfaction but improves healthcare utilization and outcomes as well (Gornick, Eggers, Reilly, Mentnech, Fitterman, Kucken, Vladeck, 1996; Laviest & Nuru-Jeter, 2002, Laviest, Nuru-Jeter, & Jones, 2003).  This evidence supports the need for continued efforts to increase the number of minority NP providers.

Implication for Nursing Practice:  The U. S. continues to face a serious shortage of primary care clinicians at a time when demands for health care services are expected to rise, particularly in rural and underserved areas.  NPs as primary care providers, if allowed to practice to the full extent of their licensure, could impact health care outcomes for Southern citizens.  The National Center for Workforce Analysis (2013) projected a national primary care provider shortage of 6,400 FTE in 2020. Compared to the length and cost of physician education, the mobilization of a new NPs can occur more quickly at a relatively lower cost.  In addition, NP education and practice typically builds on the expertise and experiences of seasoned registered nurses, who often represent a wide array of ethnic and cultural backgrounds.  A renewed emphasis on educating more NPs to meet growing primary care demands would likely improve the diversity of healthcare providers.  Furthermore, greater support for NP residencies (as encouraged in the IOM [2010] report) focused on rural and underserved areas may actually lead to improved care at a lower cost among these highly underserved and vulnerable populations.