Horse Hooves, Hay and Primary Care: New Course Gives DNP Students Rural Perspective

10/08/12  Portland, Ore.

Give up a week in the summer, away from family, friends and your job?

by Lee Lewis-Husk
 Horses with a rainbow
Give up a week in the summer, away from family, friends and your job?That’s exactly what 15 students did to participate in a new and sought-after course offered in La Grande to OHSU students working toward a DNP degree. As a result, rural citizens may receive better health care.

Faculty in the rural health track created the Urgent and Emergent Rural Primary Care Management for Nurse Practitioners course to help advanced practice nurses become better informed and educated about rural health. It features simulated learning, didactic lectures and a special twist.

Associate Professor Gary Laustsen, Ph.D., F.N.P., R.N., punctuates his lessons with a field trip to his farm outside La Grande where students learn how ranch injuries occur.

“We raise hay, chickens, horses, and I show how farm machinery can damage a person. We walk around my farm and look at the risks. I have a 1,900 pound horse with hooves the size of dinner plates. What would it be like to have the horse kick or bump into you?” he asks rhetorically.

The farm visit fits perfectly with the course purpose: to help students learn to perform acute care procedures they might need in a rural practice and also how to evaluate and treat those patients. “In rural areas, you don’t necessarily have an emergency room across the street; it could be 50 miles away,” he says. “If you’re an NP in primary care in a rural area, you might need to know how to perform advanced suturing, read an EKG or X-ray, and put on a splint.”

Education born of research
The course is based on results of an OHSU Betty Gray Foundation-funded study Laustsen did with NPs. He queried 1,450 Oregon practitioners about the frequency and skills needed in practice and looked at differences between urban and rural. The results helped fill a gap in the literature about actual skills needed by nurse practitioners and provided direction for evidence-based education. “One of the big differences is that rural NPs don’t see the same frequency of problems as urban nurses but see a greater breadth of conditions,” says Laustsen.

Armed with specific data from the study, Laustsen and colleague Kristi Vaughn, D.N.P., A.P.R.N., assistant professor, developed a weeklong intensive class at the school’s La Grande campus to teach skills often needed in a rural primary care practice.

Both Laustsen and Vaughn bring a wealth of experience to the course. Not only does Laustsen live on a farm, he’s worked as an emergency medical technician, taught trauma nursing care for the Emergency Nurses Association and worked for many years as an FNP in a hospital emergency department as well as in an urgent care center. He is interim director of the FNP Program. Vaughn teaches at the nursing school’s Portland campus and practices as an acute care NP in the OHSU Hospital Emergency Department.
The nursing school received a three-year grant from the Health Resources and Services Administration, U.S. Department of Human Services, to educate students to work better in rural areas as advanced practice nurses. The summer intensive is open to any student working toward an advanced practice degree but is required for FNPs in the school’s Rural Health Track. The track is designed to prepare expert rural advanced practice nurse leaders and to improve health care outcomes in rural communities.

Twenty-nine of the state’s 58 hospitals are rural and most of these are designated as critical access hospitals, according to the state’s Office of Rural Health. Rural citizens earn less income and have higher poverty rates than urban dwellers; they also tend be less well educated and have more unemployment. Access to health care is difficult due to a chronic shortage of practitioners and geographic distance to services. Because of their high level of education and practice independence, nurse practitioners can fill a vital role in serving rural and remote populations.

The course is built around didactic lectures, psychomotor skills and online forums.

“The didactic portion of the course was very interesting and gave a good overview of rural emergency care,” says Cindy Reed, D.N.P., F.N.P.-C., who completed the inaugural course in 2011. “The didactic provided a summary of a rural patient who might present with chronic as well are urgent care needs. The faculty guided our understanding of what labs or procedures we might order.”

Reed, who recently completed her DNP from OHSU and currently practices in Fruitland, Idaho, on Oregon’s eastern border, says the course also provided many insights on financial, legal and ethical issues facing nurse professionals in a rural or frontier area. For example, she says a practitioner may want to carry extra inventory, such as an X-ray machine or lab facilities. From a patient’s perspective, she points out that farmers or others who live in rural areas may lack health insurance and therefore tend to avoid hospitals. They often go straight to their primary care provider, even though the injury might be severe and require specialty care.

In her practice, she sees injuries from ATVs, livestock, hunting accidents and reptile, insect and other bites not typical in an urban area. “I saw a young man who tore the bottom of his foot off riding his ATV into a ditch while moving irrigation pipes,” she recounts. “He refused to go to the ER even after I explained that I couldn’t care for him appropriately.”

These types of scenarios are presented during the summer course, along with more routine problems, including triage of orthopedic, respiratory and cardiovascular emergencies; wound, burn and skin care; toxicology, and pediatric concerns. Students learn about coordinating care in a rural area where the next closest specialist or hospital might be 100 miles away.

In a simulation lab on the school’s La Grande campus, students practice suturing, splinting, X-ray reading, removal of foreign bodies and 12-lead ECG interpretation. On the last day of the course, Laustsen brings in live patients who present scenarios of rural injuries. Students do a physical assessment, determine what is wrong and then develop a treatment plan for that patient.

Feedback from the first class was positive. “The in-person portion of the class was fun and informative,” wrote one student. Another said, “I really enjoyed the ‘intensive concept,’ out of town.” Their enthusiasm apparently spread because this year’s class filled quickly. “More people wanted the experience than we have space or faculty for,” says Laustsen.

Laustsen and Vaughn are also spreading the word. In April this year, they took first prize for their electronic poster presentation at the National Organization of Nurse Practitioner Faculties meeting.  “How to Treat a Cow Bite: A Course in Skills and Rural Issues for FNP Students,” presentation outlines the goals of the weeklong summer intensive.

And in October 2011, at the International Rural Nurses Conference in Binghamton, NY, Laustsen, presented, “What do Rural NPs Do? A Task Analysis of Rural NPs in Oregon.”

“The fact that OHSU makes a commitment to this and does it in a rural area is extremely important,” says Reed. “You can’t get a true picture of rural, frontier care in an urban area.” She says OHSU’s educational efforts to boost rural health care go hand in hand with Oregon’s largely rural population and the state’s support of independent practice by NPs in an outpatient setting.

Thanks to OHSU’s focus on rural health, the dedication of faculty and students willing to spend a week in Eastern Oregon during the summer, rural areas around the state and country stand to gain practitioners who’ve had a first-hand look at rural life and practice.


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