"We have the physicians we need—how can we successfully recruit and retain Physician Assistants, Nurse Practitioners, nurses and other health professionals?"

A vital part of creating well-rounded and efficient delivery of health care services in any community is attracting and retaining an adequate and efficiently functioning supply of “other” health professionals, that is, non-physician providers.

This broad range of caregivers includes allied health practitioners whose services are independent from, but complementary of, the services provided by physicians, for example, dentists, chiropractors and physical and occupational therapists. It also includes health care givers whose roles essentially support the medical care of doctors, such as all levels of nursing and clinical staff. So-called “mid-level providers,” such as physician assistants (PAs), certified nurse midwives (CNMs) and nurse practitioners (NPs), act as “physician extenders,” supplying direct patient primary care in cooperation with or under the supervision of a licensed physician (medical director), often in rural and satellite family-care clinic settings.

With 171 of Texas’ 536 hospitals located in rural counties and the population in these counties accounting for 16 percent of the state’s total, meeting the need for qualified professionals in rural areas is a continuing challenge. According to published research, the barriers to bringing health professionals to rural areas and keeping them there can be generalized. These include lifestyle issues such as lower wages compared to urban areas, lack of social activities, lack of employment opportunities for spouses and lack of access to academia or continuing education.

Other challenges confronting nurses and allied health workers in expanded roles are the breadth of knowledge and skill competencies required in rural settings and a lack of acceptance from traditionally minded physicians.

This Toolbox Section concentrates primarily on the recruitment and retention of nurses, particularly registered nurses (RNs), and mid-level providers in the light of their importance in community-based strategies to increase the availability of quality health care services for rural populations. It also touches on aspects of rural care provided by pharmacists and chiropractors as two examples of niches filled by other health professionals.

Nurses:

According to major data sources, most of the United States, including Texas, is suffering from a shortage of nurses, especially registered nurses. Though deficits in the supply of nurses tend to run in cycles, this current staffing crisis is expected to peak during the next decade. Major factors cited as contributing to the shortage include an aging workforce (with a concurrent decline of enrollment in nursing schools and an increase in retirements), stresses attributed to work environment and the appeal of job opportunities outside nursing.

Hospitals and health systems employ stop-gap measures to address nurse staffing shortfalls that include temporary wage hikes, hiring and shift differential bonuses, the use of per diem nursing pools and recruitment of traveling, foreign and National Health Service Corps (NHSC) nurses, and recruitment of military nursing corps staff who are entering the civilian workforce. Some facilities have also experimented with “triage by phone”—toll-free telephone lines staffed by specially trained nurses who help callers deal with minor injuries or illnesses and refer more serious cases to further care. Still other areas are turning to increased use of “parish nurses,” or faith-based volunteers, and lay health workers, commonly known by the Spanish term of promotoras, to fill patient-referral holes in the system.

Some communities are applying a more long-term strategy by “growing their own” nurses. Recruitment activities concentrate on students, from middle-school age through college age and career-changing adults. Retention strategies are often based on scholarships or tuition repayment plans offered by employers to workers who desire to advance their careers while remaining on staff for a committed length of time.

(See Toolbox Section Recruitment Beginning With Students), for scholarship information. Other retention efforts include providing nurses with career-track incentives, or increasing their access to continuing education options.

Retention of nursing staff is not simply a matter of wage/salary/benefits issues. Much has been written about nursing burnout and its contributing causes. Recent studies by both the American Nurses Association (ANA) and Texas Nurses Foundation (TNF) point to workplace issues such as inadequate staffing, non-supportive nursing management, concerns about compromised patient outcomes from increased patient loads, lack of access to technological advances and inflexibility in shift scheduling.

An encouraging turn of events is the number of collaborative solution-oriented focus groups that are springing up across the state, in areas suffering from acute nursing shortages as well as in those just beginning to grapple with the problem. Partners include nursing professionals, academic institutions and faculty offering nursing degree programs, small and large hospitals and health systems and administrators, and state and nonprofit organizations such as the Texas Nurses Association (TNA) and Area Health Education Centers (AHECs).

Mid-level Providers:

Mid-level providers include physician assistants, nurse practitioners of various specialties and certified nurse-midwives, most of whom provide patient care in clinic settings. The demand for these physician extenders in rural Texas varies widely by area, and a recent growth trend seems to be slowing, primarily as a side effect of health system-wide funding cuts in response to negative changes in Federal and state health benefits program reimbursements.

Research has indicated that recruitment and retention barriers for physician assistants are similar to those of physicians in any given locale, because the two practices are linked by structure, i.e., PAs must work with a supervising physician). There is a proven link between practitioners who come from rural backgrounds, and those who eventually establish their practices in rural areas. (See Toolbox Section Physician Recruitment)

Compared to physician assistants, the reasons why nurse practitioners settle in practices where they do are not as clear-cut, though reasons cited by NPs in research surveys include previous knowledge or working relationship with the hospital or clinic; location of spouse’s employment; availability of continuing education/professional advancement opportunities; and a positive working environment.

Certified Nurse Midwives (CNMs) are registered nurses that have completed a graduate level program in nurse-midwifery, through traditional clinical education programs and licensure through the state nursing board. This training allows them to provide obstetrical and gynecological care for women during pregnancy, childbirth and the postpartum period. CNM educational programs are accredited by the American College of Nurse Midwives (ACNM) and recognized by the U.S. Department of Education. These programs must also meet the standards of the Board of Nurse Examiners for the State of Texas (BNE).

Currently, there are three nurse midwifery educational programs in Texas, the Parkland School of Nurse Midwifery, Dallas (affiliated with the University of Texas Southwestern Medical Center) http://www3.swmed.edu/midwifery/midwifehome.html, the Nurse-Midwifery Program at the University of Texas at El Paso/Texas Tech University, http://www.nurse.utep.edu/nursing/degree.programs/midwife.htm and the University of Texas Collaborative Nurse Midwifery Education Program, University of Texas Medical Branch, Galveston. http://www.utmb.edu (For a listing, by state, of nurse-midwifery programs, go to http://www.acnm.org/edu/masters.cfm )

The BNE has continuing education requirements for advanced practice nurses, including Certified Nurse Midwives.

Certified Nurse Midwives (CNMs) say their most common barrier to practice is finding a partnering physician who will agree to accept back-up referrals for high-risk or emergency maternal patient care. Another issue is client insurance coverage (or lack thereof) for midwife services. Even though a Pew Health Professions Commission Task Force urged midwifery to be included in managed care plans (April 19, 1999), and prominent health journals regularly report positive outcomes from midwife-managed births (33 percent lower neonatal mortality risk, for example, reported in the Journal of Epidemiology and Community Health, MacDorman M, Singh G, 1998; 52:310-317), the health professions community as a whole fails to acknowledge midwives.

Documented (lay) Midwives are direct-entry midwives, meaning they are not required to be nurses. In Texas, direct-entry midwives are documented under the Texas Department of Health Midwifery Program. http://www.dshs.state.tx.us/plc Their education is based on the current Core Competencies and Standards of Practice of the Midwives Alliance of North America (MANA) and the Texas Midwifery Basic Information and Instructor Manual, which is created and approved by the Texas Department of Health. There are currently three direct-entry midwifery programs approved by the Texas Midwifery Board: The Association of Texas Midwives Midwifery Program, Tyler; Maternidad la Luz, El Paso; and the Medical Training Institute of America Midwifery Program, Dallas. The Midwifery Board also has continuing education requirements for Documented Midwives.

Midwifery has not been embraced as the partial solution to gaps in maternal health care access that it could be, except in scattered or border areas of Texas. The state lags the U.S. in the supply of practicing midwives, though there has been a slight increase of practitioners in the past five years. As of 1999, only 203 certified nurse-midwives were practicing in the State of Texas (Texas Department of Health, health professions’ report, 1999, http://www.dshs.state.tx.us/chs). As of the September 2003 report, on Supply Trends Among Licensed Health Professions in Texas, 1980-2002, that figure had increased to 276 Certified Nurse Midwives and 155 Direct Entry Midwives, with growth evidenced primarily in metropolitan counties.

Other Health Professionals:

Other common areas of concern for communities seeking to improve the health status of their members are access to affordable dental care and recruiting and retaining pharmacists (who are beginning to fill an expanded preventative health advisory role as they monitor clients’ medical data profiles while filling prescriptions). Communities also find themselves constantly engaged in assessing healthcare trends and addressing their need to fill such interdisciplinary niches, asking, for example, “Do we need, or could we use providers such as physical therapists, home health care aides or chiropractors in our town or region?”