Advanced Practice Nurses Fill Health Care Gaps in Rural Areas

by Candi Helseth

These days, Laura Thiem is the only “doc” in Adrian, Mo. But Thiem isn’t a physician—she’s a certified family nurse practitioner. Four years ago, after the local rural health clinic where she worked had closed, Thiem opened a primary care clinic on Main Street in Adrian, a town of 1,500 that she has called home for many years. Now Thiem sees and treats approximately 4,000 patients a year.

Ninety-three miles away, Marti Cowherd, who is certified as both a family and pediatric nurse practitioner, owns and operates the Family Practice of Ray County, a rural health clinic in Richmond, Mo., a city of about 6,000. When the physician who owned the clinic decided to leave Richmond in 2004, Cowherd purchased the practice.

“We serve a population of patients that probably wouldn’t have health care if I weren’t here,” Cowherd said. “On average, we see about 25 patients a day. Most of them are on Medicaid or Medicare. Or they have no insurance.”

Laura Thiem

Laura Thiem provides mental health and primary care services in her nurse-owned clinic in Adrian, Mo.

Managed care networks, changes in states’ health care practice laws, and lack of primary care physicians in rural areas are among factors that have contributed to an increase in nurse-owned and operated clinics. In every state, nurse practitioners are now allowed to prescribe medications, and in 13 states (and the District of Columbia) they can write prescriptions independent of physician involvement. Twenty-three states allow nurse practitioners to practice independently without physician collaboration or supervision, according to Polly Bednash, CEO of the American Association of Colleges of Nursing (AACN).

As primary care providers, Advanced Practice Registered Nurses (APRNs) can perform physical exams, diagnose and treat acute and chronic illnesses, provide immunizations, order X-ray and lab tests, and do other routine care similar to what is offered within the scope of a general physician practice. APRNs are among the growing population of registered nurses seeking advanced degrees and more responsibility. In 2008, 13.2 percent of the nation’s registered nurses held either a master’s or doctoral degree. Demand for nurses with advanced degrees far outstrips the supply, according to AACN.

Nurse practitioners offer primary care

At the University of Missouri-Columbia’s Sinclair School of Nursing, a nurse practitioner program is helping fill gaps in rural and underserved urban areas where primary care would otherwise be unavailable, said Shirley Farrah, Assistant Dean of Nursing Outreach. MU’s nurse practitioner program enables rural nurses to get advanced training through distance learning programs, completing the majority of their course work from the locations where they live. Farrah, who teaches a business component for nurses, said traditional nursing programs don’t prepare nurses for the business side of operating a practice.

“We currently have several nurse practitioners practicing in rural areas,” said Lila Pennington, a MU nursing professor. “Most of our nurse practitioners are settled in these areas and have family there. If you can educate people who live in the rural area and like living there, they are more likely to continue to live and work there.”

In its 2009 AMA Scope of Practice Data Series: Nurse Practitioners report, the American Medical Association argued that nurse practitioners and nurses with doctorate degrees do not offer care equivalent to that offered by licensed physicians.

But, Bednash said, “It does not take 11 years of a physician in medical school to competently immunize a child, treat an ear infection or sore throat, give a physical exam, or even manage diabetes or high blood pressure. APRNs provide this level of care and can be prepared at a much lower cost. An APRN will refer patients with complicated cases to a primary care or specialist physician in the same way that physicians refer complicated cases to specialists. Currently, the vast majority of APRNs are being prepared in master’s and doctoral degree programs requiring three to four years of advanced education.”

Demand for doctors greater than supply

Nor is there an abundance of physicians to supply primary care needs, particularly in rural areas. Physician demand will outpace supply by 2025, according to a report, The Complexities of Physician Supply and Demand, issued by the Association of American Medical Colleges in November 2008. The report suggests that “non-physician clinicians such as physician assistants, nurse practitioners and others” can adequately provide some services “usually provided by physicians.”

Marti Cowherd

Marti Cowherd, who owns and operates a rural health clinic in Richmond, Mo., says the satisfaction in her work comes from caring for multiple generations of patients.

While the majority of Cowherd’s medical practice consists of low-income, uninsured patients, the majority of Thiem’s patients have medical coverage. What the patients all have in common is that they live in a rural area where access to care would be almost non-existent if it weren’t for the nurse-owned clinics.

“I’m always busy,” said Thiem, who is also certified as a psychiatric mental health clinical nurse specialist. “I provide the medical home for these patients. I know the families and their medical history. A good portion of my practice is medical management for patients with chronic diseases. But I also spend a lot of time addressing mental health issues.”

According to Farrah, 80 to 90 percent of primary care issues seen in physician offices can be handled by nurse practitioners. Just as primary care physicians refer patients to specialists when patients need more care, nurse practitioners refer patients to physicians when a problem is outside the scope of the nurse practitioner’s practice, Farrah noted. Pennington added that numerous research studies have shown that in primary care settings, patient satisfaction and outcomes are at least equal to that of physician primary care.

“Like any family practice clinic, a lot of my time is spent seeing acute and chronic care needs—patients with diabetes, high blood pressure, cholesterol issues, kids with ear infections, colds, etc.,” Cowherd said. “I see everyone from premature babies to 97-year-old ladies. The satisfaction for me comes from caring for families, for generations of patients. I get to see and know the grandparents, grandkids, even great-grandkids and have the opportunity to take care of them when they’re sick and also when they’re well.”

Resources on Nursing

For more information on nursing in rural areas, see the following Rural Health Information Hub resources:

RHIhub Topic Guides


Funding Programs

Contacts and Organizations

  • RHIhub’s Directory of Rural Health Contacts: Nurses (No longer available.)

Rural Health Models and Innovations Hub

For additional sources on nursing and nursing degrees, visit the websites of the following nursing organizations:

Back to: Spring 2010 Issue