In Montana, 52 of 56 counties are classified as medically underserved and ten counties have no physician. This is why nurses play such an important role there, and why the Montana Office of Rural Health/Area Health Education Center (MORH/AHEC) is working to get more nurses in rural, underserved communities.
“Montana is different than other states because of our extreme frontier nature, so nurse practitioners (DNPs) have a full scope of practice here,” said Kristin Juliar, MORH/AHEC Director. “In many communities, they may be the sole primary care practice, and physician supervision is some distance away.”
Using a grow-your-own approach, MORH has joined with the Montana State University College of Nursing (MSU CON), where it is housed, to get more nurses trained and working in rural areas. The effort has been funded by two Health Resources and Services Administration grants, Nurse Education, Practice, Quality and Retention (NEPQR), which prepares BSN-level nurses to work in rural primary care, and Advanced Nursing Education Workforce (ANEW), which trains rural-ready DNPs.
Kailyn Mock, MORH Project Coordinator, said the best ANEW candidates are already working in rural settings. “We are trying to leverage their skill set,” Mock said. “They have dug their heels into their town, are working already as an RN, and want to continue work in their communities. They can provide a different level of service to their communities as a DNP.”
“Our DNP program is an all-online program so it’s especially suited to advance their education in rural,” Juliar said. “We have DNP students from all over the state. If you are a DNP in a rural setting you need a broader set of skills than you would need in a more urban clinic. The ANEW grant is focused on establishing academic clinical partners with Critical Access Hospitals (CAHs), Community Health Centers (CHCs), tribal and Indian health, and Rural Health Clinics (RHCs), and developing the curriculum to help those nurses working in those settings.”
ANEW students do their schoolwork from their homes and communities and do not go to class unless there is a skills lab requirement a couple of days in a row at the start of the semester, Mock said. “We also set up clinicals outside of where their usual job is, to help them find an experience outside of what their normal practice looks like,” she said.
For the NEPQR grant, students are enrolled in a traditional brick and mortar program based on campus, Juliar said. MORH works with MSU CON on the outreach component of the grant, and to help develop undergraduate nursing didactic education so that it is in line with the needs of rural and underserved sites in Montana, she said.
“There’s a focus on establishing more clinical sites, and getting more students out into primary care settings, like CHCs, CAHs, RHCs, and tribal health sites,” Juliar said. “We also are looking at trends in healthcare transformation and care coordination models, and how nurses can be up to speed on these developments in how health care is delivered.”
Undergraduate nursing students who elect to be in the Rural Primary Care Track receive additional education through the AHEC Scholars Program, which focuses on interprofessional education and team-based care, Mock said. “These students also have priority preference for completing the clinical component of their coursework in rural locations.”
NEPQR grant funding began in July 2018 and ANEW grant funding began in July 2019, Mock said. Both are four-year grants. “Our first ANEW cohort started at the end of last summer with 15 in the first group, and we have 21 students lined up for 2020-2021,” she said.
The NEPQR grant supports rural immersion costs for undergraduate nursing students, including travel costs to rural sites for clinical rotations, and conference registration fees. The ANEW grant covers all tuition, plus up to $9,000 for books and clinical travel.
The grants represent a partnership between MORH/AHEC and MSU CON to address critical rural health workforce issues, Mock said.
Providing healthcare to all parts of Montana is challenging, with 1,068,778 people spread across 145,546 square miles. Finding nurses to work in rural Montana is especially challenging because most nurses in the state work in urban areas and the nursing workforce is aging, with the average age of all nurses around 49 years old.
But Mock sees hope in getting more rural students into nursing school. “Our best success stories are those who grow up in rural returning to rural,” she said.