Fourth in a Series: "Nothing Has More Strength than Dire Necessity"

Jun 29, 2011, 1:45 PM, Posted by

The AARP Solutions Forum: “Advancing Health in Rural America: Maximizing Nursing’s Impact,” was held on June 13. This post is the fourth in a series in which Robert Wood Johnson Foundation (RWJF) Nurse Faculty Scholars share their thoughts on the ideas presented. The author, Elizabeth A. Kostas-Polston, Ph.D., A.P.R.N., W.H.N.P.-B.C., is an assistant professor at Saint Louis University School of Nursing. Find out more about the forum or view the archived webcast.

Nearly one in four Americans—70 million people—live in rural America. On average, they are older, poorer, more likely to be uninsured, and suffer from higher rates of chronic health conditions.1

For the past 15 years, I have lived in south central Missouri, in a small town—population ~12,000 rural Americans. I am a nationally, board certified Women’s Health Nurse Practitioner and Colposcopist. In this role I participate by providing primary and specialty health care to rural, underserved and uninsured women who are often the target of Healthy People 2020 indicators. What’s more, the women I care for are not just faces in the crowd. They are my children’s teachers, colleagues’ wives and daughters, the lady who waits on me at the post office, the woman who rings up my groceries, my children’s friends, and my friends’ daughters—all of whom make up our community. It is no surprise, then, that the primary aim of my practice is to improve the health of women and their families. Improving the health of women and their families, in turn, positively impacts the health of our community.

As I listened to nurses such as the Honorable Mary Wakefield and Gail Finley share their thoughts regarding the challenges and opportunities that simultaneously exist as Nursing purposely and strategically moves to make its mark on the improvement of health care in rural America, I could not help but reflect on the numerous barriers which continue to interfere with my ability to practice to the full extent of my education, training, and competence.

Although there are multiple barriers, I will focus on three which I view as key if change is to occur. It is essential that these three barriers be purposefully and thoughtfully tackled so as to advance a health care agenda for America. Further, we will not see improvements in access to and quality of health care unless nurses are front and center in leadership, education, training, and in the design of a new model for health care delivery.

These critical barriers: 1) regulatory laws (both federal and state), 2) payment (reimbursement for services), and 3) interprofessional collaboration.

Regulatory laws govern the activities of various administrative agencies of the federal and state governments. Government agency action can include rulemaking, adjudication, and/or the enforcement of a specific regulatory agenda. Current regulatory laws negatively impact Nurse Practitioners in that they tie our hands. The great flux and variation in federal and states’ regulatory laws result in frustration, confusion and discordant practice from state to state. For example, scope of practice issues, certifying home health care visits or stays in skilled nursing facilities or hospice, ordering of durable equipment, admitting patients to hospitals with/without a physician’s supervision or collaborative agreements, and prescribing medications with/without physician oversight, vary from state to state 2. Further, in many states regulatory laws mandate harsh requirements in regard to physician supervision. It is notable that the Federal Trade Commission is evaluating current and proposed state regulatory laws in light of their anticompetitive nature.3 Stay tuned for the Federal Trade Commission’s final assessment.

As if existing regulatory laws are not enough to contend with, the Nurse Practitioner’s role and identity are constantly susceptible. For example, many master’s prepared Nurse Practitioners are returning to university seeking a Doctor of Nursing Practice (DNP) degree.4 Although contentious, this model of education and training is grounded in the belief that the preparation necessary for advanced nursing practice is the doctorate-level. Currently there are 153 DNP programs enrolling students nationwide and there are an additional 160 DNP programs in the works.5 Nurse practitioners graduating from such programs are conferred with the degree and title of doctor (Dr).

In response to this, for example, the Missouri State Senate, in March of 2011, put forth the following legislation for a vote. SB 303. 334.250 number 3 read: Any person who uses the title "Doctor", "Dr.", "M.D.", or "D.O." within a hospital as defined by section 197.020, or within an ambulatory surgical center as defined by section 197.200, and is not now or has not been a registered physician within the meaning of the law or is not now or has not been licensed as a physician in another state or territory shall be guilty of a class D felony. Senators who wrote the bill as well as those supporting the bill were inundated with emails and phone calls expressing, among other things, the bill’s ridiculous nature. At the final minute, the bill was pulled resulting in no vote. If it has not yet become apparent to the reader, Nurse Practitioners are constantly challenged. We are challenged and often held to a more rigorous standard as clinicians, by federal and state regulatory laws which govern what we can and cannot do, and by medical organizations which have repeatedly opposed a bigger and more independent role for Nurse Practitioners in health care reform and delivery.

Payment (reimbursement for services) is another barrier to Nurse Practitioner practice. Payment of Nurse Practitioner services are also linked to regulatory laws. For example, scope of practice barriers directly increase the cost of health care services. An example of this includes payment to the physician for unnecessary oversight and chart reviews.

In an attempt to address payment barriers, the Institute of Medicine has put forth recommendations to federal agencies to remove scope of practice barriers.6 These include: 1) expanding Medicare to include coverage of APRN (Advanced Practice Registered Nurse) services within the practice of applicable state law; 2) authorizing APRNs to perform Medicare admission assessments and certification of patients for home health, hospice, and skilled nursing services; 3) changing the Centers for Medicare & Medicaid Services (CMS) requirements for Medicare hospital participation to ensure that APRNs are eligible for clinical and admitting privileges; 4) increasing Medicaid reimbursement rates for APRNs providing primary care services; and 5) urging states to amend unduly restrictive state APRN regulations.7 These recommendations were made based on years of research supporting the delivery of effective, safe, and efficient health care by Nurse Practitioners.8 The implementation of payment reforms which are proposed in the Affordable Care Act (ACA) will hopefully help to ease tensions and fears by physician providers while enhancing support for the removal of Nurse Practitioner scope of practice barriers. An example of payment reform is the medical-home model.

Improving quality, safety, and access to health care and reducing costs are the reasons interprofessional collaboration is essential for practice in today’s complex practice settings. Poor communication and lack of teamwork are consistent with barriers to interprofessional collaboration. Interprofessional team delivery of comprehensive health care services has been shown to increase patient satisfaction, increase efficiency and reduce costs through decreased hospitalizations, length of stays, number of emergency room visits, drug prescriptions, and more home discharges. To assure true coordination for quality and safe care that is also efficient, all health care providers must work interdependently in an environment of mutual respect, trust, support, and appreciation of each other’s professions’ unique contributions to health care. Improvements realized when working in this type of environment include, for example, avoidance of duplication of services and unnecessary procedures, and provision of the most appropriate and timely care.

In rural settings, Nurse Practitioners do what we have to do to get the job done. The economics are such that we have to be creative when determining how to best use scarce resources. I often refer to this as creative nursing. We rely heavily on the grace, kindness, and expertise of our interprofessional colleagues.

I remember one situation involving a 14 year-old young woman. She came to the clinic for family planning services. We confirmed that she was not pregnant, yet on exam was found to have an enlarged uterus. And, not just a little enlarged, but one the size of a 4 ½ month pregnancy! On exam, I found her uterus (or so I thought) to be hard as a rock, non-mobile, non-tender and filling her entire pelvis. The young woman’s family had no insurance and no money. She needed to have an ultrasound. Our Director of Nursing, an experienced, public health, registered nurse, and I together made phone calls and had the young woman worked in locally for an ultrasound that afternoon. How our clinic was going to pay for the ultrasound remained to be seen! The ultrasound findings were consistent with a huge adnexal mass. I was later to find out that in fact, it was a 7-pound, benign, adnexal mass.

I will never forget how long and hard we worked to access the resources and expertise necessary for further evaluation—more than eight days of phone calls, pleading, insisting, arguing, and finally, begging... Unfortunately, no physician would see the young woman as she, at the time, had no insurance, no Medicaid, no way to pay. Referring her to a physician colleague-friend in the city two hours away was not an option as her parents had no vehicle and could not afford to pay for the gas. Even when we received a preliminary “ok” phone call from the Missouri Medicaid office, no provider in our town would agree to evaluate her. In fact, the provider who finally saw her, while she and her parents sat anxiously in his waiting room, insisted that his business manager herself speak to the Missouri Medicaid office to confirm coverage and benefits.

The reason that I am sharing this experience with you is not to place blame, but rather to point out how problematic our current health care system is. Although the young woman needed to be evaluated, one cannot blame the physician for hesitating to see her. After all, physician colleagues have an obligation to the business end of their practices as well as to their families and those whom they employ.

In my 15 years living in rural America, I have seen many a physician colleague relocate because the dollars which they were reimbursed for services by either third party payers or self-pay patients were not enough to make ends meet. Hence, payment (reimbursement of services) is not only a barrier for Nurse Practitioners, but all health care providers. The Affordable Care Act (ACA) seeks to reduce health care costs while maintaining quality and safe care provided by a team of health care professionals working together to address their primary concern—the patient! In antiquity, the Greek playwright Euripides infamously said, “Nothing has more strength than dire necessity.” Dire necessity? The time is here and now! My only response to that is, “Why has it taken so long?

Read more about the AARP Solutions Forum: “Advancing Health in Rural America: Maximizing Nursing’s Impact.”


1Gorski MS. Advancing health in rural America: Maximizing nursing’s impact. June 2011. Fact Sheet FS227, AARP Public Policy Institute, Washington, DC.

2Fairman JA, Rowe JW, Hassmiller S, and Shalala D. Broadening the scope of nursing practice. N Engl J Med. 2011 Jan 20;364(3):193-6. Epub 2010 Dec 15. PMID: 21158652.

3Shalala D. Keynote presentation: Initiative on the future of Nursing. November 12, 2010. American Academy of Nursing 37th Annual Meeting & Conference. Grand Hyatt Washington, Washington, DC.

4American Association of Colleges of Nursing. AACN position statement on the practice doctorate in nursing. October 2004. (

5American Association of Colleges of Nursing. The Doctor of Nursing Practice (DNP). April 2011. (

6Institute of Medicine. The future of nursing: Leading change and advancing health. 2010. Institute of Medicine, Washington, DC.

7Gorski MS. Advancing health in rural America: Maximizing nursing’s impact. June 2011. Fact Sheet FS227, AARP Public Policy Institute, Washington, DC.

8Institute of Medicine. The future of nursing: Leading change and advancing health. 2010. Institute of Medicine, Washington, DC.


This commentary originally appeared on the RWJF Human Capital Blog. The views and opinions expressed here are those of the authors.