1. 1 Copyright © 2012 by Mosby, an imprint of Elsevier Inc. Copyright © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Chapter 19 Population-Centered Nursing in Rural and Urban Environments

2. 2 Copyright © 2012 by Mosby, an imprint of Elsevier Inc. Copyright © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Objectives 1. Compare and contrast definitions of rural and urban. 2. Describe residency as a continuum, ranging from farm residency to core inner city. 3. Compare and contrast the health status of rural and urban populations on select health measures. 4. Analyze barriers to care in health professional shortage areas and for underserved populations.

3. 3 Copyright © 2012 by Mosby, an imprint of Elsevier Inc. Copyright © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Objectives, Cont’d 5. Evaluate issues related to delivery of public health services for rural underserved populations. 6. Describe characteristics of rural and small-town residency. 7. Examine the role and scope of public health nursing practice in rural and underserved areas. 8. Evaluate two professional-patient-community partnership models that can effectively provide a continuum of health care to residents living in an environment with sparse resources.

4. 4 Copyright © 2012 by Mosby, an imprint of Elsevier Inc. Copyright © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Historic Overview  Formal rural nursing originated with the Red Cross Rural Nursing Service (1912).  Prior to this service, care of the sick in small communities was provided by informal social support systems.  Problems faced by rural communities for generations  Maldistribution of health professionals  Poverty  Limited access to services  Ignorance  Social isolation

5. 5 Copyright © 2012 by Mosby, an imprint of Elsevier Inc. Copyright © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Definition of Terms Rurality: A Subjective Concept Rural-Urban Continuum

6. 6 Copyright © 2012 by Mosby, an imprint of Elsevier Inc. Copyright © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Rurality: A Subjective Concept  Increasing degree of urban influence on rural communities; differences between rural and urban are not as distinct as they once were  Rural is defined in terms of the geographic location and population density, or it may be described in terms of the distance from (e.g., 20 miles) or the time (e.g., 30 minutes) needed to commute to an urban center.  Farm residency versus nonfarm residency  Each town has its own distinction

7. 7 Copyright © 2012 by Mosby, an imprint of Elsevier Inc. Copyright © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Rural-Urban Continuum  Relative nature of ruralness  Rather than seeing rural and urban residencies as opposing lifestyles, they must be seen as a rural-urban continuum, ranging from living on a remote farm, to a village or small town, to a larger town or city, to a large metropolitan area with a core inner city.  Metropolitan area  Micropolitan area  Non-core area  Suburbs

8. 8 Copyright © 2012 by Mosby, an imprint of Elsevier Inc. Copyright © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Rural-Urban Continuum, Cont’d

9. 9 Copyright © 2012 by Mosby, an imprint of Elsevier Inc. Copyright © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Current Perspectives Population Characteristics: Rural Health Status of Rural Residents

10. 10 Copyright © 2012 by Mosby, an imprint of Elsevier Inc. Copyright © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Population Characteristics: Rural  More Caucasians  Higher proportion of younger (under 18 years of age) and older residents (over 65 years of age)  More likely to be married  More likely to be widowed  More likely to be poorer  Fewer years of formal education  At risk for being underinsured or uninsured

11. 11 Copyright © 2012 by Mosby, an imprint of Elsevier Inc. Copyright © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Health Status of Rural Residents  Perceived health status  Chronic illness  Rural-urban health disparities  Physical limitations  Availability and access of health care  Health professional shortage area (HPSA)  Patterns of health service use  Maternal and infant health  Health of children  Mental health  Health of minorities  Environmental and occupational health risks

12. 12 Copyright © 2012 by Mosby, an imprint of Elsevier Inc. Copyright © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Rural Health Care Delivery: Barriers to Care  Lack of health care providers and services  Great distances to obtain services  Lack of personal transportation  Unavailable public transportation  Lack of telephone services  Unavailable outreach services  Inequitable reimbursement policies for providers  Unpredictable weather and/or travel conditions  Inability to pay for care/lack of health insurance

13. 13 Copyright © 2012 by Mosby, an imprint of Elsevier Inc. Copyright © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Rural Health Care Delivery: Barriers to Care, Cont’d  Lack of “know how” to procure publicly funded entitlements and services  Inadequate provider attitudes and understanding about rural populations  Language barriers (caregivers not linguistically competent)  Care and services not culturally and linguistically appropriate

14. 14 Copyright © 2012 by Mosby, an imprint of Elsevier Inc. Copyright © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Nursing Care in Rural Environments Theory, Research, and Practice Research Needs Preparing Nurses for Rural Practice Settings

15. 15 Copyright © 2012 by Mosby, an imprint of Elsevier Inc. Copyright © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Theory, Research, and Practice  Body of literature on rural health is growing  Most publications focused on hospital practice but information is applicable to both community agencies and community-focused nursing  Physical isolation:  Professional isolation for nurses  Scarce financial, human, and health care resources  Broad scope of practice

16. 16 Copyright © 2012 by Mosby, an imprint of Elsevier Inc. Copyright © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Research Needs  Rural nursing deserves more recognition  Stressors and rewards of rural practice  Empirical data on particular community nursing needs of rural-patient systems  International perspective on health of rural populations  Most efficient and effective way to use technology in rural health care  Distance learning  Rural-urban disparities in health status

17. 17 Copyright © 2012 by Mosby, an imprint of Elsevier Inc. Copyright © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Preparing Nurses for Rural Practice Settings  Need broad knowledge about nursing, including:  Health promotion  Primary prevention  Rehabilitation  Obstetrics  Medical-surgical specialties  Pediatrics  Planning and implementing community assessments  Understanding the public health risks and needs for emergency preparedness in a particular state  Telehealth

18. 18 Copyright © 2012 by Mosby, an imprint of Elsevier Inc. Copyright © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Future Perspectives Scarce Resources and Comprehensive Health Care Continuum Healthy People 2020

19. 19 Copyright © 2012 by Mosby, an imprint of Elsevier Inc. Copyright © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Scarce Resources and Comprehensive Care Continuum  Needed in most rural areas:  School and parish nurses  Family planning services  Prenatal and postpartum services  Resources for individuals diagnosed with HIV/AIDS and their families  Emergency medical services  Resources for families of children with special needs, including those who are physically and mentally challenged  Mental and mental health services  Resources for older adults

20. 20 Copyright © 2012 by Mosby, an imprint of Elsevier Inc. Copyright © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Healthy People 2020  Rural Healthy People 2010: A Companion Document to Healthy People 2010  CDC’s Healthy Communities Initiative  Healthy Communities: A Rural Action Guide (North Carolina Smart Growth, 2004)

21. 21 Copyright © 2012 by Mosby, an imprint of Elsevier Inc. Copyright © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Building Professional- Community-Patient Partnerships in Rural Settings Case Management Community-Oriented Primary Health Care (COPHC)

22. 22 Copyright © 2012 by Mosby, an imprint of Elsevier Inc. Copyright © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Case Management  A patient-professional partnership that can be used to arrange a continuum of care for rural patients, with the case manager tailoring and blending formal and informal resources  Allows patients to participate in their plan of care  Outcomes are often remarkably different when case management is used

23. 23 Copyright © 2012 by Mosby, an imprint of Elsevier Inc. Copyright © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. COPHC  An effective model for delivering available, accessible, and acceptable services to vulnerable populations living in medically underserved areas  Emphasizes flexibility, grassroots involvement, and professional-community partnerships  Blends primary care, public health, and prevention services, which are offered in a familiar and accessible setting  Is interprofessional, uses a problem-oriented approach, and mandates community involvement in all phases of the process