The purpose of this presentation will be to describe the didactic and experiential curricular modifications used to help prepare students and faculty for the rural traineeship.
Methods:
We determined that the course, “Health Promotion/Disease Prevention”, taken the semester prior to our dual track nurse-midwife.women's health nurse practitioner students’ first clinical rotation, to be well-suited for the addition of rural health content. Modifications included: a) a Rural Health module developed with input of a nurse-midwife rural health consultant from Appalachia who shared her stories of “rural midwifery “ using ZOOM meetings along with key resources (ACOG, 2014b; Bolin et al., 2015), b) an assignment in which the students used a tool “Minding Your Own Business” to conduct a holistic health assessment of the rural community (Crozier & Melchior, 2013) and c)short answer reflections to prompts in their final examination. The latter two modifications will be the focus of the presentation.
“Minding Your Own Business” is a tool that the rural health consultant provided to guide the students in an assessment of the health and resources available of the rural mountain community. The preamble of the tool reads:
Use a Health and Physical Assessment format to conduct a Community Needs Assessment. This is a good way to investigate, organize, and through this holistic approach, see how we create, and are created by our community. This semester, your findings will be a vehicle to become acquainted with the community of Lake Arrowhead and its adjacent communities. Your findings will help inform the activities that CSUF WHC students and faculty will do in partnership with Mountains Community Hospital and Rural Clinics to improve access to women’s health services.
Women’s Health Concentration graduate nursing students were assigned the task of assessing the health of the rural mountain community partner. Of note: the students were concurrently taking their Health Assessment course so they were learning how to perform a holistic physical examination on an individual in the same semester that they experienced assessing the health of a rural community. In groups, students went to the rural community and interviewed health care providers, business owners, and residents of the community. Their findings were presented to staff and administrators in the rural health system and to faculty.
In their final examination, students responded to two prompts related to their rural community assessment experience: a) “based on the course readings and your personal experience in Lake Arrowhead/San Bernardino County, what are the area's greatest needs (name at least three) in terms of health promotion and disease prevention? Please include citations from the course readings in your answer” and b) “Personal reflection; what did you learn during the community assessment that will inform how you provide care for women/families in rural areas?”
Results:
Narrative analysis was used to identify themes from the responses of the students. A grid will be presented that summarizes the sub-themes in the health care priorities assessed by the students: Women’s Healthcare Services/Prenatal care, Mental Health, Substance Abuse, Preventative Health/Health Screening, Access to Health Services. In addition, further detail as to the experiential aspects of the rural health assessment will be provided.
Popular phrase encountered by all students was “down the mountain” and "40 minute drive during good weather"
Women’s Healthcare Services/Prenatal care
|
Mental Health |
Substance Abuse |
Preventative Health/Health Screening |
Access to Health Services |
Other |
|
|
Crucial time in educating moms Promoting healthy fetal development Women;s HC services including prenatal care Women in rural areas at greater risk of hospitalization due to pregnancy-related complications statistically, women in rural areas have higher incidence of maternal/infant mortality Women’s services, especially prenatal care Only form of contraception provided is oral medications and condoms predominantly a pro-life community no abortion services Only office procedure is pap-smear Provided with one free ultrasound Then must establish care with a provider Non-profit organization associated with church provides educational materials/resources and ongoing support during pregnancy Actively recruiting obstetrician Increasing health services for women – access and availability Must travel 30 minutes for prenatal or OB-GYN services Primary need is obstetrical and gynecological care Residents unaware of the role and services provided by a CNM Educated patients on the benefits of CNM/WHNP services Teen pregnancy Oral contraceptive available Teenagers can be forgetful to take pills Afraid to ask for access Without clinician that can insert IUDs or implants in arm Area does see a high teen pregnancy Hard for teens related to access to transportation, education, fear of being found out if receiving birth control Culturally acceptable to be a teen mother. Prevent unintended teen pregnancy Rate very high One SN for 3300 students Not have time to provide pregnancy prevention educationan result in negative SE consequences Refer to CM to apply medical supplies/home care do they have CM?? Need for obstetrical care No access to birthing center Hospital is for emergencies only Limited OB/GYN provider care Pregnant women must travel down the mountain for care Postpartum and contraceptive needs may not be met |
Typically overlooked Essential to assess for anxiety/ depression Mental health Mental health needs Mental health issues exacerbated in rural areas Rural residents less likely to seek or receive MH care NPs at Lake Arrowhead report many patients have significant MH needs Psychiatric services available via telemedicine Women in poverty Higher incidence of mental illness Need for MH treatment Mental illness a prominent problem affecting 2/3 of patient population Women in poverty Higher incidence of mental illness
|
High rate Drug prevention Implement drug programs in schools Number of available programs indicates need for prevention Crystal meth popular drug Causes tooth decay Oral hygiene Drug education prevention Meth problem in community Little drug addiction resources/education Education/health promotion regarding substance abuse Substance abuse Substance abuse rates in rural areas approximate the rates in urban areas FNPs described extensive experience with large number of people demonstrating drug-seeking behavior Crestline has “a big drug problem” Substance abuse Intimate partner violence Usually co-occurring Women at Lake Arrowhead at high risk of becoming homeless due to partner’s or own drinking problems
|
Cardiovascular Lifestyle changes Educate patients Promote self-awareness Knowledge of disease Manage own health Preventative care/screening services Rural areas have lower resources and less usage of preventative services Less screening for breast/cervical cancer Less educated Only one school nurse for thousands of students Single school nurse for 3000 students Lack of education and resources for community education Overwhelmed by job duties Rurality requires more effort to prevent disease/promote health No public health department Community Vital Signs was created by SB county to create healthier evironment Access to preventative care/health promotion, esp WH & OB care Access to health care Rely on community clinic and hospital to get routine check-ups PCP can provide screening, dx, treat chronic/acute illess Treatment at the early stage
|
Likely to be lower SE class Lack health insurance Consider financial incentives to providers Providers still did not stay on very long Some did not stay the allotted time Implement computer-based telemedicine Would open door to increased screening Reach more of population Become an empathetic and sincere advocate Healthcare access Limited access is a major barrier Residents note disparities between those financially comfortable and those who struggle When financial concerns take forefront, more difficult to think about health Living in mountainous terrain increases difficulty in accessing health services Difficult to get services if they lack transportation Limited number of specialists May not have money or too cold to use the bus Other barriers are obtaining time off Temporary/seasonal employment associated with vacation communities Few specialists Access HC resources Many referred to hospital emergency room Refer to SW to apply for health insurance Increase access to providers/services Lack of providers Lack of access and providers Lack of medical providers Need for additional medical services Less PCP = less preventative care Need more practitioners, support, access
|
Oral hygiene Proud of ability to fly someone out by helicopter during an emergency Can’t afford healthy foods Unable to exercise Link between poverty and low education connected to obesity Must consider these needs when creating plans of care
|
Conclusion: The enhanced curricular and experiential content provided better understanding of the health and socioeconomic issues in the rural mountain clinics. Nurse-midwife/Women's Health Nurse practitioner students as well as faculty were better prepared to start clinical training in the rural health clinic.