Running head: GROWING RURAL APRN PROVIDERS

Recruiting Rural Nurses to Become Advanced Practice Registered Nurses in Rural Colorado
Ingrid M. Johnson
Arizona State University

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GROWING RURAL APRN PROVIDERS

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Recruiting Rural Nurses to Become Advanced Practice Registered Nurses in Rural Colorado
Abstract
Rural healthcare leaders are increasingly tasked with the responsibility of providing
health access to 21% of the national population with only 10% of the provider workforce
(Sonenberg, Knepper, & Pulcini, 2015). Provider recruitment strategies offering loan repayment
have had some success in the short term, but are less impactful at creating a long-term retention
rate, unless the providers have an existing connection to either the community in which they are
working or rural healthcare (Renner et al., 2010). Responding to this data, a demonstration
project has been created in Colorado to test a rural focused “grow your own” advanced practice
registered nurse (APRN) model. This model is designed to recruit RNs from inside rural
communities to return to school and become primary care providers within those communities
upon graduation. The project offers stipend support with assistance in the school application
process, educational support, clinical and job placement assistance, and monthly coaching.
Additionally, communities are asked to provide matching funds to support the APRN students
with a goal of creating a self-sustaining model that will build a continuous pipeline of APRN
providers. This strategy avoids the costly need to recruit and relocate providers who have no ties
to the community. The initial response from rural nurses and communities around the state has
been overwhelmingly successful. This success suggests that this model could serve as a new and
sustainable strategy for building a rural APRN provider workforce pipeline while ensuring
access to a primary care health provider for all people living in rural areas.

Keywords: rural, nurse practitioner, provider, shortage, recruitment

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Problem, Purpose and Rationale
The looming shortage of health care providers in rural areas creates access to care
barriers in these communities. There is a need for recruitment strategies specifically targeted at
APRNs to provide access to quality health care for this underserved patient population. The
purpose of this paper is to assess what types of recruiting techniques are the most effective in
targeting nurses currently living and working in rural and underserved communities to return to
school to become APRN providers within rural communities.
Background and Significance
Primary care provider (PCP) shortages have been a topic of discussion in the United
States for many years. The Future of Nursing Report (Institute of Medicine, National Academy
of Sciences [IOM], 2011) cited a variety of credible sources that were reporting anywhere from
severe current PCP shortages to looming expected shortages (IOM, 2011). The Patient Protection
and Affordable Care Act (ACA), created a significant influx of newly insured people whom, as
expected, would take the opportunity to access needed healthcare (Sonenberg, Knepper, &
Pulcini, 2015). This influx exacerbated a national primary care physician provider shortage,
estimated at between 35,000 and 44,000 between 2005 and 2025 (Bodenheimer & Pham, May,
2010). Numerous efforts to recruit physician providers to move to rural and frontier communities
have been tried with very limited success (Sharp, 2010).
Research suggests that recruiting providers who are not from or committed to a specific
community has not successfully created a pattern of long-term retention of those providers
within the communities in which they have agreed to serve (Renner et al., 2010). However,
APRNs have proven to be a very flexible workforce that is much easier to both build and
distribute to areas in need of providers (Morgan, Johnson, & Fraher, March, 2015). Additionally,

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APRNs from a given community have been shown to have a higher probability of long-term
retention within that community. Building a local provider workforce of APRNs could serve to
mitigate the provider shortage and improve access to healthcare for rural residents (Auerbach et
al., 2013). Fully educating and mobilizing APRNs as PCPs in both the general population and
provider shortage areas could greatly alleviate the current and looming PCP shortage, serving to
provide increased access to care to those most in need (HRSA, 2013).
Evidence also indicates that APRNs have been shown to be more prone than physicians
to practice in rural and underserved areas when their practice is not unduly limited by statutory
barriers (Federal Trade Commission [FTC], March, 2014).
Although not exclusionary to APRNs, most projects in the state focused on building a
PCP rural workforce continue to favor rural physician recruitment and are not specifically aimed
at recruiting additional APRNs in rural areas (Renner et al., 2010). Evidence supports that
APRNs could serve to fill the void of providers in those areas, mitigating the provider shortage
challenge (Auerbach et al., 2013; Health Resources and Services Administration Bureau of
Health Professionals [HRSA], 2013).
The PICO question utilized for this topic therefore is; For rural community nurses (P)
what extrinsic recruiting techniques (I) compared to no recruiting techniques (C) affect the
nurses decision to attend school and return to practice as an APRN within the rural
community(O)?
Literature Search Strategy, Critical Appraisal and Synthesis of Evidence
An exhaustive literature search was carried out using CINHAL (Appendix A), PsycInfo
(Appendix B), and PubMed (Appendix C). The limited amount of high level existing evidence
on this subject created a need to clearly identify what elements were essential in utilizing an

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existing study. All studies chosen were published in the last 10 years, with many having been
published within the last five years. Additionally, because of the need to ensure rigor in these
studies, each chosen study was identified in the search as peer reviewed. This was crucial
because of the lack of level I, II and III evidence. The final criteria for utilizing the literature
revolved around the population, subject and clarification of whether each resource was a primary
or secondary resource.
All studies were independently reviewed with the data carefully evaluated, synthesized,
and separated for inclusion in the Evaluation (Appendix D) and Synthesis (Appendix E) Tables.
Ultimately, sixty-nine studies were retained for review.
Contribution of Theory
Social Capital Theory
The evidence cited in the Evaluation Table (Appendix D) and the Synthesis Table
(Appendix E) lends itself to the Social Capital Theory (Lauder, Reel, Farmer, & Griggs, 2006)
which focuses on social connectedness within a community. The idea behind this theory is that
human beings are socially interconnected. Capitalizing on existing resources within a community
allows that community a sense of self sustainability (Lauder et al., 2006, p. 74). Involvement in a
given community and social participation builds trust, networks and support systems (Baum &
Ziersch, 2003). Evidence indicates these elements are vital components in rural recruitment as
indicated in the Synthesis Table (Appendix E). Rural health professionals and their patients
often are closely connected within their communities. This connection creates a trust-based
relationship, ensuring “transition costs (are) low because of mutual trust, reciprocity and
interpersonal relationships are strong” (Lauder et al., 2006, p. 78).
Tyler Collaborative Model (TCM) for Evidence-Based Nursing Practice

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The TCM (Appendix F) was created as a strategic collaborative model designed to
eliminate barriers to utilizing research for more effectively initiating evidence based practice in
nursing (Olade, 2004). Rural nursing workforce recruitment is a subject that has been studied and
discussed. However, evidence suggests that little emphasis has been placed on creating an
effective evidence based practice to more efficiently recruit nurses to rural and underserved
communities. Although created with a focus on EBP at the bedside, the model combines Lewin’s
and Havelock’s change theories (Olade, 2004) creating a new model designed to allow all
practice within nursing to have an EBP foundation; including rural nurse recruitment. The model
is designed to create EBP by following three phases. The first is the Unfreezing Phase which has
a three step process; building relationships, diagnosing the problem, and acquiring resources.
The second phase is the Moving Phase. Two steps are identified at this stage; choosing a solution
and gaining acceptance. The third phase is the Refreezing Phase. This final step focuses on
stabilization of the process to implement the EBP. Utilizing this model in gathering information
on rural nurse recruitment allows full synthesis of the available evidence regarding best practices
for rural nurse recruitment.
Methodology
Plan for Application of the Evidence
Two Colorado based private foundations have looked at the evidence on rural provider
maldistribution and the challenges of health access in rural communities. Both provided funding
to test a demonstration project designed to build an APRN provider workforce from the existing
nursing workforce in rural Colorado. Available evidence supports the idea that providers are
more likely to stay and practice in a rural community if those providers are from a rural
community (Bigbee & Mixon, 2013). Initial data necessary to identify where providers are

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needed focused on the location of Colorado Health Provider Shortage Areas (HPSAs). Upon
identification of where providers were needed, the intervention was to recruit existing nurses in
those areas through the public health departments, schools, federally qualified healthcare
facilities (FQHCs), critical access hospitals and local nursing organizations. The recruitment plan
included an offer of financial support for a return to school through a stipend, assistance with the
school application process, employer support, mentoring, and accessing community matching
funds. All nurses accepted to the program, titled the Rural and Underserved APRN Project, are
required to either be living or working in a rural and/or underserved community or from a similar
community with plans to return. Additionally, each participant is contractually obligated to stay
and work in a rural and/or underserved community for two years for every year funding is
provided. The project will fund 40 new APRNs. The Nursing Community Apgar Questionnaire
(NCAQ), a validated survey designed to measure elements that impact recruitment and retention
of rural nurses, has been used to measure outcomes (Prengaman, Bigbee, Baker, & Schmidtz,
2014; Prengaman & Bigbee, 2016).
Ethics Approval
Approval was obtained through the Institutional Review Board at Arizona State
University to begin data collection from the nurses accepted to participate in the Rural and
Underserved APRN Project. The IRB number is: STUDY00004736 : Rural APRN Recruitment.
Nursing Community APGAR Questionnaire
Thirty-six nurses had been accepted into the program at the time data collection began.
Approval was obtained from the authors of the NCAQ to use it as a measurement tool in the data
analysis. The NCAQ is a survey consisting of 50 factors grouped into five classifications of 10
factors each (Prengaman et al., 2014). The survey separately rates the advantages/challenges and

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the importance of the geographic, economic, management/decision making, practice
environment, and community practice support classifications to the respondents decision to
return to school and become local providers.
Each participant was sent the NCAQ survey via Survey Monkey in a web link. All
identifying characteristics of each participant were blinded in the on-line survey, including email
and IP addresses to ensure anonymity of the participants.
Data Collection
Thirty-six registered nurses (RNs) living and/or working in a rural and/or underserved
community were asked through email with a web link to survey monkey to complete the survey.
Thirty-four RNs completed at least some of the survey and returned it, which is a 94% response
rate. Twenty of the surveys were completed and returned with incomplete data; therefore the
final sample size varies among the classifications according to the number of questions
completed within that classification.
Participants were asked to rate each factor first as either an advantage or challenge and
then on its level of importance. A four-point Likert scale was assigned to each corresponding
score. The advantage/challenge ratings were scored as: ‘major advantage’ = 2, ‘minor advantage’
= 1, ‘minor challenge’ = -1, and ‘major challenge’ = -2. The importance ratings scores were:
‘very important’ = 4, ‘important’ = 3, ‘unimportant’ = 2, and ‘very unimportant’ = 1 (Prengaman
et al., 2014).
Additionally, each participant was asked to respond to two open-ended questions
surrounding their decision to return to school and become a provider within their community.
This allowed a qualitative element to enhance the richness of the data, but the questions were

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provided via on-line format, not face to face as is the accepted methodology of a qualitative
questionnaire. The questions are:


“What are your greatest barriers to returning to school and becoming an APRN provider
in your community?”



“What can be done to overcome these barriers?”

Data Analysis
Descriptive statistics was used to describe the sample population and the outcome
variable (NCAQ) and each domain of the NCAQ scale. The One Sample Kolmogorov-Smirnov
(K-S) test, a non-parametric test, was used to assess goodness of fit and clarify how the sample
population was distributed. SPSS® 24 was utilized to analyze the statistical data (IBM, 2016).
The Critical value was set at p<0.05.
Findings
Sample Population
Thirty-four (N=34) registered nurses living and/or working in a rural and/or underserved
community responded to the survey. The average age of respondents was 37.4 (SD= 8.0) years of
age and the ages ranged from 25 to 53 years old. The average number of years the respondents
had been practicing as registered nurses was 11.1 years (SD= 8.0) and the number of years
ranged from 2 to 29. Thirty-three (97.1%) respondents reported currently living and/or working
in a rural and/or underserved community and thirty-two (94.1%) respondents identified
themselves as female. Twenty-six (77.0%) respondents reported having been raised in a rural
and/or underserved community. The majority of the sample (N=24) report their ethnic
background as Caucasian (70.6%) and ten (29.4%) self-identify as coming from other ethnic
backgrounds (Appendix H).

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During the recruitment phase of the Rural and Underserved Program, ethnic background was
not identified; however, utilizing holistic admission techniques (Glazer et al., 2016) and
identifying professional merit and an interest in serving the targeted communities created a
population of nurses that self-identifies as over 29% diverse. This is aligned with state-wide
diversity levels in Colorado as reported by the census bureau, suggesting ethnic heterogeneity of
the data that is in line with the overall state demographics (United States Census Bureau, 2015).
Each domain of the NCAQ survey was evaluated. The average score on the
Management/Decision Making Importance Scale was 36.10 (SD=3.90) and the scores ranged
from 28 to 40. The average score on the Practice Environment Importance domain was 37.00
(SD=3.15) and the scores ranged from 30 to 40. These two categories appear to have the most
impact on decisions of the respondents to return to school (Appendix I).
The average score on the Practice Environment advantage/challenge was 7.0 (SD=9.41)
and the scores ranged from -13 to 20 (Appendix I). These findings suggest that the nurses see the
practice environment as an advantage in their decision to return to school. However, the K-S test
does not support that outcome as significant (p=.137). The overall advantage/challenge mean
score in the Economic category provides the only negative mean of -.50 (SD=13.20) and the
scores range from -16 to 20 (Appendix I). These findings suggest Economic issues are a strong
challenge in the decision to return to school.
Clinical Significance
Respondents indicated that the biggest advantage to returning to school and becoming a
provider in a rural and/or underserved community is the emphasis placed on patient safety and
quality care. This is followed by the family-friendly environment, high level of autonomy and
respect, ethical climate and strong partnerships between medicine and nursing. The lowest rated

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mean item scores identifying the highest challenges to returning to school are listed in Table 1
(Appendix I). The challenges most frequently listed are economic housing availability and
affordability, costs of day care, shift differential pay, geographic access to a larger community,
and salary. The items rated as most important to support a return to school and decision to serve
as providers in a rural and/or underserved community are listed in Table 1 (Appendix I). Those
items include: positive workplace culture/supportive environment, emphasis on patient safety,
job satisfaction/morale, professional development opportunities and autonomy and respect.
Qualitative Findings
A text analysis was run on the open-ended questions included in the survey through
Survey Monkey. That analysis identified the most commonly used words and terms in
responding to each of the two open-ended survey questions. The most commonly used words and
terms in responding to the question, “What are your greatest barriers to returning to school and
becoming an APRN provider in your community?” are the following: school, cost, financial,
family, money, community, commitment, funding, living, and rural. Responding to the question,
“What can be done to overcome these barriers?” respondents most frequently used the following
words or terms: scholarships, programs, financial assistance, school, flexible, rural, support, cost,
and financial support.
Significance and Implications for Practice
The statistical evidence gained through the use of the NCAQ strongly supports the
evidence identified in the initial literature search. Nurses within rural communities are willing to
return to school and become providers within those communities, but are in need of support.
Most significant is the suggestion that nurses will be drawn into becoming providers in their
communities if the practice environment within those communities is supportive of nurse

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practitioners. They appreciate a positive working environment with local physicians as well as
the management/decision making entities of local health care organizations. 100% of the nurses
accepted into the Rural and Underserved APRN program verbally report working either part or
full time while they attend school. Organizations can support building the APRN workforce by
providing flexibility in their work schedules while they attend school. All are contractually
obligated to stay and work in a rural and/or underserved community for a minimum of two years
for each year they receive stipend funding. Employers within rural communities can be very
impactful in building an APRN workforce from within their own locality. This can be done by
drawing upon talented local nurses and helping connect them with accredited APRN programs
designed for nurses living and working in a rural area.
Additionally, respondents indicated that their biggest challenge in returning to school is
financial. Communities and employers have the opportunity to provide financial assistance with
a requirement of service following education. This serves to decrease financial barriers to the
students and improve access to providers within the community upon graduation. Doing so
creates the opportunity to build a sustainable primary care provider workforce from local nurses.
Respondents indicate that they find living in a rural community an advantage. Data from
traditional loan repayment/relocation programs that draw upon providers from outside the
community suggest that providers who relocate do not perceive the rural community positively
unless they are from a rural community. This creates a culture in which providers move to rural
communities as a requirement of loan repayment, but largely are not retained in those
communities once their rural placement commitment is complete (Renner et al., 2010). Providers
who are relocated to a community report challenges in helping their spouse or partner find
employment (Glasser, Peters, & MacDowell, 2006). When providers are built from within the

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existing community, spouses and partners are already engaged within the community and finding
employment is not an issue. Respondents indicated the importance of their family-friendly
environment, but did not identify challenges regarding spousal satisfaction as is often seen when
providers are relocated (MacDowell, Glasser, Fitts, Fratzke, & Peters, 2009).
Respondents indicated in the open-question section of the survey that they can be more
successful if schools are open to creating rural-friendly programs that are either hybrid or fully
on-line. Schools are moving toward holistic admission practices, which focus more on life
success than academic success and have shown an equal outcome in academic success rates for
students (Glazer et al., 2016). Regis University Loretto Heights School of Nursing responded to
this need by creating a rural and underserved APRN cohort using a holistic admission to test the
success of the Rural and Underserved APRN participants. Twelve members of the program
applied and were accepted into this program, which is a hybrid design requiring the students to
come to campus for a few successive days each semester with most of the education provided in
synchronous on-line courses. All students report a high level of appreciation for a program
designed around their remote locations. Creating collaborations between rural communities with
provider shortages and accredited APRN schools creates opportunities for acceptance into school
while allowing participants to remain in their communities.
The practical implication of this work suggests that areas and organizations experiencing
health care provider shortages have the opportunity to build a sustainable provider model from
within. Rural communities and local healthcare organizations and businesses can quickly initiate
actions to build an APRN provider workforce, locally. The most impactful actions that can be
done at the community level are; provide financial assistance and workplace flexibility,
collaborate with rural-friendly accredited APRN programs, and build a defined willingness

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within organizations and with other providers to work with APRNs. Allowing APRNs to
practice to the full extent of their education and experience is important. The nurses want to
know there will be a place for them to serve as providers once they have completed their
education.
Limitations
Missing data from individual variable answers created a total score that did not include
scores of 58% of the respondents because SPSS does not include partial responses in the total
score. The NCAQ tool was designed to be given face to face, which would allow the researcher
to ask for all data to be answered, generally, even if it didn’t specifically impact that respondent.
Because the tool doesn’t include a ‘not applicable’ answer, it left a void in capturing some of the
data. However, the ability to create the survey in an on-line format provides the opportunity to
reach more respondents in a shorter amount of time without the need to travel across the state to
meet with each respondent. Since the survey wasn’t originally designed to be given in this
format, the unanswered questions created unexpected challenges with missing data.
The sample was a convenience sample accessed through the rural and underserved nurses
who were accepted into the Rural and Underserved APRN program. Each is required to have a
monthly phone call with the researcher to assess if the added support impacts their success in
completing the educational process. This is an opportunity for follow-up research on how
mentoring/coaching can impact student success. However, for the purposes of this research, it
made it very difficult to ensure the data analysis remained focused on the survey responses only.
Knowing each participant so well and understanding the issues they identify monthly as
challenges made it difficult to retain objectivity in reading the data. An objective and unbiased
statistician was asked to review the data and provide feedback on the data analysis to ensure

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there was no bias in the analysis. The respondents were not coached on how to answer survey
questions. They were simply asked to read the directions, answer honestly, and return the
surveys. The statistical data supporting the significance of a positive practice environment and
management and decision making support was clear in the data and identified by the statistician
as well as the researcher.
Each respondent was recruited into the Rural and Underserved Program with the promise
of financial assistance in addition to other types of support. The fact that each respondent was
already receiving financial assistance at the time the survey was completed may have mitigated
the level of economic challenges identified by the participants. This may be one reason economic
challenges are repeatedly mentioned in the qualitative, open-ended question responses, but are
not shown as significant in the statistical data.
Opportunities for Further Research
Full assessment of the impact of this project requires follow-up on retention data as well
as recruitment. This project is only the initial phase of a three phase research project. Phase one
identifies external elements important for recruitment of rural nurses to become APRNs within
their communities. Phase two will measure graduation rates of those nurses and phase three will
measure retention rates of the APRNs from this project in rural and underserved communities
after five years.
Conclusion
The evidence in the literature indicates that providers from rural communities are more
likely to stay and practice in rural communities (Renner et al., 2010). Using this as a foundation,
creating a new homegrown APRN workforce could change the face of the rural provider
workforce and how that workforce is built. Social Capital Theory states that in order to create

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sustainability within a community, there must be an interconnected network of trusted and
committed members (Lauder et al., 2006). APRNs can be educated and serve while working in
the rural communities in which they live, are committed, and have a support system with no need
to relocate. The literature suggests that physicians rarely choose to practice for the entirety of
their career in rural, and if they go to rural, it is unlikely they will stay there (FTC, March, 2014).
APRNs can be built from within that community. The statistical data identified in this project
support that nurses will opt for a return to school to become providers when provided financial,
employment and community support. Full success of an APRN primary care provider model
requires an acceptance of APRNs within communities as well as a willingness to break down
barriers to practice so these professionals can practice to the full scope of their education and
experience (Auerbach et al., 2013). Statutory barriers continue to exist for APRNs in many
states, which serve to limit the ability of those states to utilize APRNs to mitigate provider
shortages (IOM, 2011). This model for primary care provision in rural and underserved
communities could become the accepted and expected model. Growing a provider workforce
from local RNs has the potential to create a pipeline of APRN providers across all rural and
underserved areas of the country to help eliminate the primary care provider shortage.

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Shannon, K. C., & Jackson, J. J. (2011). A study of predictive validity of physician assistant
students’ reported practice site intent. The Journal of Physician Assistant Education,
22(2), 29-32.
Sharp, D. B. (2010). Factors related to the recruitment and retention of nurse practitioners in
rural areas (Unpublished doctoral dissertation). University of Texas , El Paso.
Skinner, H. G., Coffey, R., Jones, J., Heslin, K. C., & Moy, E. (2016). The effects of multiple
chronic conditions on hospitalization costs and utilization for ambulatory care sensitive
conditions in the United States: a nationlly respresentative cross-sectional study. BMC
Health Services Research, 16(77), 1-8. http://dx.doi.org/10.1186/s12913-016-1304-y

GROWING RURAL APRN PROVIDERS

21

Sonenberg, A., Knepper, H., & Pulcini, J. (2015). Implementing the aca: The influence of nurse
practitioner regulatory policy on workforce, access to care, and primary care health
outcomes. Poverty and Public Policy, 7(4), 337-356.
The Colorado Center for Nursing Excellence. (2015). Colorado’s future healthcare workforce
and the role of advanced practice registered nurses. Retrieved from
http://coloradonursingcenter.org/aprn-report
United States Census Bureau. (2015). http://www.census.gov/quickfacts/table/PST045216/08
Zheng, J., Li, J., Jiang, X., & Zhang, B. (2015, April 18). Sustaining health workforce
recruitment and retention in township hospitals: a survey on 110 directors of township
hospitals. Front Med, 9(2), 239-250. http://dx.doi.org/10.1009/s11684-015-0292-0

GROWING RURAL APRN PROVIDERS
Appendix A
CINAHL Database

22

GROWING RURAL APRN PROVIDERS
Appendix B
PSYCINFO Database

23

GROWING RURAL APRN PROVIDERS
Appendix C
PUBMED Database

24

GROWING RURAL APRN PROVIDERS

25
Appendix D
Evaluation Table

Citation

Theory/
Conceptual
Framework

Design/
Method/
Purpose

Sample/Setting

Major Variables
Studied and
Their Definitions

Measuremen
t/
Instrumentat
ion

Data
Analysis

Findings/
Results

Level of evidence/
Decision for
Use/Application to
Practice

Blaauw, D. et al.
(2010). Policy
interventions that
attract nurses to
rural areas: a
multi-country
discrete choice
experiment.

Not stated,
but suggests
a focus on
Value
theory –
Asks what
nurses value
in an area in
which they
choose to
work.

Design=
Non-experimental design
survey- discrete choice
experiment -crossectional
research :

N=1064

Nonexperimental
design survey

Discrete
choice
experiment
(DCE)-

Chow
Test

Suggests that
DCE data can
be used to help
policy makers
identify
interventions to
address rural
shortages. Also
offers insight
into what
interventions
would be most
effective.

LOE IV:

Location: Kenya,
South Africa,
Thailand

Method=
Mixed logic modelmultistage cluster sampling
model

Funding: UK
Department of
International
Development

Purpose= Evaluate the
effectiveness of different
policies in attracting nurses
to rural areas in Kenya,
South Africa and Thailand
using data from the
discrete choice experiment.

Bias: None noted

Peer Reviewed = Y

Demographics
= RN students in
Kenya, S. Africa
and Thailand
Setting=
Classroom
setting – last
year of nursing
school

Response rate=
100%

DV1:Nursing
students from
rural areas
DV2: Nursing
students from
urban areas

Data from
systematic
review of
larger cohort
longitudinal
study.

Strengths: number,
content focus,
maldistribution
challenges, randomized.
Strong Lit Review
Weaknesses: Location –
DCE could have been
more clearly defined.
Conclusion: Showed
rural nurses more likely
to stay in rural, but HR
interventions have
positive impact on
retention
Feasibility: Useful as

AAPA – American Association of Physician’s Assistants, AHRQ – Agency for Healthcare Research and Quality, APRN – Advanced Practice Registered
Nurse, AR – Arkansas, CAF – Critical Access Hospital, CEO – Chief Executive Officer, CNM – Certified Nurse Midwife, CNS – Certified Nurse Specialist,
DCE – Discrete Choice Experiment, DV – Dependent Variable, FGD – Focused Group Discussions, GPA – Grade Point Average, HPSA – Health Provider
Shortage Area, HR – Human Resources, LA – Louisiana, LOE – Level of Evidence, LPN – Licensed Practical Nurse, MS – Mississippi, PA – Physician’s
Assistant, PAEA – Physician’s Assistant Education Association, RN – Registered Nurse, SAQ – Self Administered Questionnaire, TN – Tennessee, UK –
United Kingdom, Y - Yes

GROWING RURAL APRN PROVIDERS

26

as focus was to
gather
information

Odell, E.,
Kippenbrock, T.,
Buron, W., &
Narcisse, M.
(2013). Gaps in
the primary care
of rural and
underserved
populations: the
impact of nurse
practitioners in
four Mississippi
delta states.
Location: Rural
Southern USA
Funding: Unclear
Bias: Nursing
focus could
suggest desire of
researchers to
support broader
scope of practice
in rural southern

study shows
maldistribution of
providers between rural
and urban is an
international challenge.
Not stated in
the research,
but could be
based in
Emancipat
ory Nursing
Practice. –
identifies
the
emancipator
y intent that
NPs in rural
have to
participate
in the care
of the
disadvantag
ed and
achieve
change.

Design=
Non experimental
research design
Methods=
Survey ResearchExamine differences
between APRNs working
in HPSA versus nonHPSA and rural versus
urban
Peer Reviewed = Y

N = 479
Demographic=
APRNs from
Mississippi
delta:

Cohort sample –
nonexperimental
research design –
cohort survey

Setting =
Arkansas,
Louisiana,
Mississippi,
Tennessee

Variables:
DV1=HPSA
DV2=Non-HPSA
DV3=Rural
DV4=Urban

Response Rate =
8%

AR = 132
LA = 166
MS = 114
TN = 67

24 item
survey –
consisted of
questions on
demographic
s,
certification,
place of
employment,
specialty,
salary
Tested with
30 APRNs
who provided
feedback
regarding
clarity, flow,
appropriatene
ss – edited
based on
group
recommendat
ions

Multiple
logistic
regressio
n models

Rural APRNs
more likely to
practice
primary care
than urban.Younger
APRNs more
willing to work
in rural. –
financial impact
was important

LOE :V
Strengths: Location
focus of rural,
population, focus of
study aligned with
PICOT
Weaknesses: low
response rate to survey
(8%), limited
geographical area
Conclusion: more
research with focus on
APRN in rural and
underserved – will need
to consider incentives to
retain more experienced
APRNs
Feasibility: Useful
because of population
and recruitment focus

AAPA – American Association of Physician’s Assistants, AHRQ – Agency for Healthcare Research and Quality, APRN – Advanced Practice Registered
Nurse, AR – Arkansas, CAF – Critical Access Hospital, CEO – Chief Executive Officer, CNM – Certified Nurse Midwife, CNS – Certified Nurse Specialist,
DCE – Discrete Choice Experiment, DV – Dependent Variable, FGD – Focused Group Discussions, GPA – Grade Point Average, HPSA – Health Provider
Shortage Area, HR – Human Resources, LA – Louisiana, LOE – Level of Evidence, LPN – Licensed Practical Nurse, MS – Mississippi, PA – Physician’s
Assistant, PAEA – Physician’s Assistant Education Association, RN – Registered Nurse, SAQ – Self Administered Questionnaire, TN – Tennessee, UK –
United Kingdom, Y - Yes

GROWING RURAL APRN PROVIDERS

27

states.

Gould, D. (2006).
Locally targeted
initiatives to
recruit and retain
nurses in
England. Journal
of Nursing
Management,
255-261.
Location:
England
Funding: None
identified
Bias: None noted
as focus was to
gather
information

There is no
stated
framework
or theory,
but this
seems to be
focused on
Grounded
Theory – as
the
information
was
gathered and
sorted into
categories
based on the
patterns of
responses

Design = Qualitative
Design –
Method = Data collected
via standardized telephone
interviews
Purpose= describe locally
targeted nursing
recruitment and retention
initiatives

N= 29
Demographic=
Experienced
nurse
supervisors at
NHS trust

Nonexperimental
design survey
research (from
formulated
interviews)

Setting= NHS
trust

DV1=Nurse
supervisors
leading
recruitment at a
NHS trust

Response Rate
= 100%

Peer Reviewed = Y
For recruitment
measures only the
supervisors were
included.

Tape
recorded
interview
transcripts
were
transcribed
verbatim and
analyzed by
content. –
Heavy
reliance on a
very solid
literature
review to
support the
findings, as
the study is
very small
and of
limited focus.

Concurren
t
gathering
and
analyzing
: data
while
categorizi
ng the
emerging
patterns of
responses.
Actual
tool is not
named in
the report,
which is a
weakness.

Organizations
reported limited
success in
advertising and
attempting to
bring new
people to their
organization.
Recruitment
focus was on
local talent.
Most effective
retention came
when nurses
were from the
area

LOE VI:
Strengths: recruitment
focus
Weaknesses: numbers
and poor explanation of
data analysis
Conclusion: Useful
because the questions
focused largely on how
organizations needing
nurses were able to most
effectively recruit
Feasibility: limited
scope of study serves the
recruitment focus

AAPA – American Association of Physician’s Assistants, AHRQ – Agency for Healthcare Research and Quality, APRN – Advanced Practice Registered
Nurse, AR – Arkansas, CAF – Critical Access Hospital, CEO – Chief Executive Officer, CNM – Certified Nurse Midwife, CNS – Certified Nurse Specialist,
DCE – Discrete Choice Experiment, DV – Dependent Variable, FGD – Focused Group Discussions, GPA – Grade Point Average, HPSA – Health Provider
Shortage Area, HR – Human Resources, LA – Louisiana, LOE – Level of Evidence, LPN – Licensed Practical Nurse, MS – Mississippi, PA – Physician’s
Assistant, PAEA – Physician’s Assistant Education Association, RN – Registered Nurse, SAQ – Self Administered Questionnaire, TN – Tennessee, UK –
United Kingdom, Y - Yes

GROWING RURAL APRN PROVIDERS

Bigbee, J., &
Mixon, D. (2013).
Recruitment and
retention of rural
nursing students:
a retrospective
study. Rural and
Remote Health, 110.
Location: Idaho,
USA
Funding: Boise
State University
Bias: None noted
as focus was to
gather
information

Long and
Weinert’s
Rural
Nursing
Theory –
“insider/out
sider”
concept

Design = Identified in
study as retrospective
descriptive design but
looks like a retrospective
cohort study.
Method = retrospective
comparison of GPA
between rural and urban
students
Purpose= Compare rural
and urban nursing students
in relation to application,
admission, and
retention/graduation trends
at Boise State University
School of Nursing
Peer Reviewed = Y

28

N=1283
Demographic =
no significant
differences
between rural
and urban
students in age,
gender, level of
ed., income.
Caucasian =
DV1=92.5%
DV2=88.7%
Setting= Boise
State University
School of
Nursing

DV1=
Rural Nursing
Students
DV2= Urban
Nursing Students

Retrospectiv
e
sample=1283
individuals to
nursing
program, 914
accepted over
5 yr. period
of study.
Compared
urban and
rural
subgroups in
GPA and
retention/gra
duation rates

Chi
square =
5.886m
p=0.015
Urban
versus
rural
acceptanc
e rates

There was no
difference
between the
success of the
rural and urban
subgroups once
they were in
school. The
rural applicants
out of high
school,
however, had a
lower
acceptance rate.

LOE IV
Strengths: Identifies
clearly differences in
rural and urban nursing
student entering school
and that those
differences are not
indicative of outcomes.
Important for rural
provider recruitment
concerns from schools.
Weaknesses: Data from
only a single institution
and limited diversity.
Feasibility = When
assessing recruitment of
rural based nurses,
shows academic success
rates.

No theory or Design=Nonexperimental
N = 28
Survey – Tool
86% reported a
Likert Scale
Chi
LOE V
framework
measures CEO
square physician
descriptive design
measured
Demographic=
stated –
responses to
survey – Not Descriptiv shortage with
Rural hospital
Strength = Rural focus
Likely
questions
stated
e
64% of that
Method= Survey Research CEOs
with discussion of
founded in
regarding
whether
the
univariate
identifying
a
– measuring with Likert
impact of community
Community
provider
shortage
survey
tool
and
need
for
family
Social
scale
involvement
Size=3,396 to
in physician and
physicians.
was validated bivariate
Capital
AAPA – American Association of Physician’s Assistants, AHRQ – Agency for Healthcare Research and Quality, APRN – Advanced Practice Registered
Nurse, AR – Arkansas, CAF – Critical Access Hospital, CEO – Chief Executive Officer, CNM – Certified Nurse Midwife, CNS – Certified Nurse Specialist,
DCE – Discrete Choice Experiment, DV – Dependent Variable, FGD – Focused Group Discussions, GPA – Grade Point Average, HPSA – Health Provider
Shortage Area, HR – Human Resources, LA – Louisiana, LOE – Level of Evidence, LPN – Licensed Practical Nurse, MS – Mississippi, PA – Physician’s
Assistant, PAEA – Physician’s Assistant Education Association, RN – Registered Nurse, SAQ – Self Administered Questionnaire, TN – Tennessee, UK –
United Kingdom, Y - Yes

Glasser, M.,
Peters, K., &
MacDowell, M.
(2006). Rural
Illinois hospital
chief executive
officers’

GROWING RURAL APRN PROVIDERS
perceptions of
provider
shortages and
issues in rural
recruitment and
retention. The
Journal of Rural
Health, 59-62.

29
33,530

Theory
Purpose = Examine
perspectives of rural
hospital CEOs regarding
recruitment and retention
of providers
Peer Reviewed = Y

Location: Rural,
Illinois, USA

Setting=Rural
hospitals in
Illinois
Response Rate
= 79% (22 out of
28 surveys
returned)

91% identified
a need for RNs
and 64%
needed
pharmacists.
Only 18%
identified a
need for
APRNs

DV1= CEO
opinions of
successful
recruitment/retent
ion elements

Funding: None
identified
Bias: None noted
as focus was to
gather
information

Brown, J., Hart,
A. M., & Burman,
M. E. (2009,
February). A day
in the life of rural
advanced practice
nurses. The
Journal for Nurse
Practitioners,
108-113.

data –
Gathered
from
Likert
scale
survey

other health
professional roles
as well as
perceptions of
elements needed
for recruitment
and retention of
health
professionals

Not stated –
Bushy’s
model
focusing on
rural health
nursing
could be
implied.

Design=Quasi
experimental design

N = 96

Method= Survey Research
– replication of a past rural
APRN study

Demographics
= APRNs,
including: NPs,
CNM, CNS,

Purpose = Examine rural
APRN practice on a typical

Setting: Rural
Wyoming

DV2= CEO
opinions of
unsuccessful
recruitment/retent
ion elements
Survey
DV1= NPs
DV2=CNMs
DV3=CNSs

Weakness = Mainly
focused on physicians
and only in rural Illinois
where APRNs do not
have full practice
authority.
Conclusion =
Community quality is
important for provider
recruitment
Feasibility = Useful
because of the provider
recruitment focus in
rural and discussion of
important community
attributes.

Survey
Research
Questionnair
e based on
Swartz et al’s
1999 study
Replication
of methods

t-test, chisquare
and
correlatio
ns with
percentag
e of visits
and
demograp

Half of all
APRNs in
Wyoming
practice in
rural. Most
have advanced
degrees. 74% in
primary care.

LOE III
Strength = Rural focus
with discussion of
impact of APRNs and
identification of how
they practice in rural
Weakness = Only

AAPA – American Association of Physician’s Assistants, AHRQ – Agency for Healthcare Research and Quality, APRN – Advanced Practice Registered
Nurse, AR – Arkansas, CAF – Critical Access Hospital, CEO – Chief Executive Officer, CNM – Certified Nurse Midwife, CNS – Certified Nurse Specialist,
DCE – Discrete Choice Experiment, DV – Dependent Variable, FGD – Focused Group Discussions, GPA – Grade Point Average, HPSA – Health Provider
Shortage Area, HR – Human Resources, LA – Louisiana, LOE – Level of Evidence, LPN – Licensed Practical Nurse, MS – Mississippi, PA – Physician’s
Assistant, PAEA – Physician’s Assistant Education Association, RN – Registered Nurse, SAQ – Self Administered Questionnaire, TN – Tennessee, UK –
United Kingdom, Y - Yes

GROWING RURAL APRN PROVIDERS

30
hic
variables

day
Location: Rural,
Wyoming, USA

Peer Reviewed = Y

Response Rate=
96/113 or 85%

Wyoming, only one day
examined, Didn’t
explain questionnaire
fully

Funding:
University of
Wyoming

Conclusion = APRNs
provide important care
in rural communities,
which often have no
other provider.

Bias: None noted
as focus was to
gather
information

Renner, D. M.,
Westfall, J. M.,
Wilroy, L. A., &
Ginde, A. A.
(2010). The
influence of loan
repayment on
rural healthcare
provider
recruitment and
retention in
Colorado. Rural
and Remote
Health, 10.
recruitment and

Not
identified in
study, but
suggestive
of Social
Exchange
Theory

Design=nonexperimental
design
Method = Survey
Research
Purpose = Assess the
influence of loan
repayment and other
factors on the recruitment
and retention of health care
providers in rural
Colorado.
Peer Reviewed = Y

N=122
Demographics
= healthcare
providers who
participated in
the Colorado
Health
Professional
Loan Repayment
Program
between 1992
and 2007.

Variables=
Physicians,
dentists, certified
nurse midwives,
physicians
assistants, mental
health specialists
DV1 =
Opted to practice
in rural because
of loan repayment
opportunity and
stayed in rural

Retrospectiv
e Sample
Survey

Chi
square

Recruitment=
Participants
rated location,
community fit
with family and
scope of
practice most
valued.
69% reported
loan repayment
option was an
important
influence on

Feasibility = Good
example of why #s of
APRNs should be
increased in rural
provider shortage areas.
LOE IV
Strengths = Rural
Colorado focus with
retrospective cohort
study of the actual
outcomes over time.
Give a strong illustration
of what impacted
retention.
Weaknesses = No focus
on APRNs and relatively
small number, although

AAPA – American Association of Physician’s Assistants, AHRQ – Agency for Healthcare Research and Quality, APRN – Advanced Practice Registered
Nurse, AR – Arkansas, CAF – Critical Access Hospital, CEO – Chief Executive Officer, CNM – Certified Nurse Midwife, CNS – Certified Nurse Specialist,
DCE – Discrete Choice Experiment, DV – Dependent Variable, FGD – Focused Group Discussions, GPA – Grade Point Average, HPSA – Health Provider
Shortage Area, HR – Human Resources, LA – Louisiana, LOE – Level of Evidence, LPN – Licensed Practical Nurse, MS – Mississippi, PA – Physician’s
Assistant, PAEA – Physician’s Assistant Education Association, RN – Registered Nurse, SAQ – Self Administered Questionnaire, TN – Tennessee, UK –
United Kingdom, Y - Yes

GROWING RURAL APRN PROVIDERS
retention in
Colorado. Rural
and Remote
Health 10:1605.

31
Setting = Rural
Colorado
Response Rate
= 93/122 =76%

Location: Rural,
Colorado, USA

decision to
practice in
rural.

DV2 = Practiced
in rural for loan
repayment, but
were not retained
in a rural setting.

Funding:
Colorado Rural
Health Center

Conclusion = Loan
repayment will get
someone to a rural
community, but will not
necessarily get them to
stay there if they have no
rural roots.
Feasibility = strongly
suggests strengths of
building a workforce
from within a rural
community as opposed
to relocating people to
rural.

Bias: None noted
as focus was to
gather
information

Shannon, K. C.,
& Jackson, J. J.
(2011). A study of
predictive validity
of physician
assistant students’
reported practice
site intent. The
Journal of
Physician
Assistant
Education, 22(2),

response rate is good.

Not stated,
but
suggestive
of Selfdeterminati
on Theory

Design = Nonexperimental
design Retrospective
cohort design
Methods = Compare
student’s surveys
completed immediately
post-rural clinical
placement with actual
practice locations
following the completion

N=168
Demographics
= PA students
who had done a
rural rotation

Cohort study
looking at
predictions of
students versus
actual outcomes.
Variables

Setting = West
Virginia

DV1 = PA
students who
predicted they

Retrospectiv
e Sample
study
Comparison
of WV
student
database –
surveys of
PA student’s
in which they
indicated a

One
tailed
Fisher’s
exact test

77% of students
who predicted
they would
practice in a
rural setting
while in school
ended up in a
rural practice.
63% of PA
students who

LOE IV
Strengths = Identifies
early predictors in what
student will go to
practice in rural. Also
has longitudinal
evidence allowing
comparison of
predictions and actual.
Provides the actual data

AAPA – American Association of Physician’s Assistants, AHRQ – Agency for Healthcare Research and Quality, APRN – Advanced Practice Registered
Nurse, AR – Arkansas, CAF – Critical Access Hospital, CEO – Chief Executive Officer, CNM – Certified Nurse Midwife, CNS – Certified Nurse Specialist,
DCE – Discrete Choice Experiment, DV – Dependent Variable, FGD – Focused Group Discussions, GPA – Grade Point Average, HPSA – Health Provider
Shortage Area, HR – Human Resources, LA – Louisiana, LOE – Level of Evidence, LPN – Licensed Practical Nurse, MS – Mississippi, PA – Physician’s
Assistant, PAEA – Physician’s Assistant Education Association, RN – Registered Nurse, SAQ – Self Administered Questionnaire, TN – Tennessee, UK –
United Kingdom, Y - Yes

GROWING RURAL APRN PROVIDERS
29-32.

of school.

Location: West
Virginia, USA

Purpose = Assess
predictive validity of PA
student’s stated intent to
practice in a rural setting in
West Virginia

Funding
provided by
AAPA/PAEA
Research Grants
Program.

32
would practice in
a rural setting just
after completing a
rural clinical
placement.
DV2 = PAs who
actually practice
in a rural setting

Peer Reviewed – Y

plan to
practice in a
rural setting
with their
actual
practice sites
after they
have
completed
education.

did not plan to
practice in a
rural setting
ended up
practicing at
least a portion
of the time in
rural.

on what brought the PAs
to a rural setting.
Weaknesses = Doesn’t
take into consideration
PAs who practice in
both urban and rural on a
part time basis.
Conclusions=Student
questionnaires are
strongly predictive of
where a student will opt
to practice.

Bias: None noted
as focus was to
gather
information

Feasibility = Useful in
comparing how extrinsic
factors impact in
recruitment of providers
to rural.
MacDowell, M.,
Glasser, M., Fitts,
M., Fratzke, M.,
& Peters, K.
(2009).
Perspectives on
rural health
workforce issues:
Illinois-Arkansas
comparison. The

Not
identified –
suggestive
of Self
Determinat
ion Theory
or may be
founded in
Normative

Design=Nonexperimental
descriptive design
Method= Survey Research
– measuring with Likert
scale
Purpose = Examine
perspectives of rural

N= 51

Survey

Demographic=
Rural hospital
CEOs

DV1= Arkansas
CAF CEO
opinions of
successful
recruitment/retent
ion elements

Setting=Rural
hospitals in
Illinois and

Likert Scale
measured
survey – Not
stated
whether the
survey tool
was validated

Chi
square
Multivaria
te analysis

Shortages exist
in both states
across provider
spectrum.
Family
medicine, OBGN and Gen.
Internal
Medicine

LOE IV
Strengths = strongly
statistical significance in
similarity of responses.
Rural focus. Mirrors
outcomes of past study,
which shows reliability
of tool.

AAPA – American Association of Physician’s Assistants, AHRQ – Agency for Healthcare Research and Quality, APRN – Advanced Practice Registered
Nurse, AR – Arkansas, CAF – Critical Access Hospital, CEO – Chief Executive Officer, CNM – Certified Nurse Midwife, CNS – Certified Nurse Specialist,
DCE – Discrete Choice Experiment, DV – Dependent Variable, FGD – Focused Group Discussions, GPA – Grade Point Average, HPSA – Health Provider
Shortage Area, HR – Human Resources, LA – Louisiana, LOE – Level of Evidence, LPN – Licensed Practical Nurse, MS – Mississippi, PA – Physician’s
Assistant, PAEA – Physician’s Assistant Education Association, RN – Registered Nurse, SAQ – Self Administered Questionnaire, TN – Tennessee, UK –
United Kingdom, Y - Yes

GROWING RURAL APRN PROVIDERS
Journal of Rural
Health, Spring,
135-140.

Economics

Location: Rural
Illinois and
Arkansas

hospital CEOs regarding
recruitment and retention
of providers

33
Arkansas
Response Rate
= 83.6%

Peer Reviewed = Y

DV2= Illinois
CAF CEO
opinions of
successful
recruitment/retent
ion elements

identified as top
shortages.
Significant
similarities
between states.

Funding: None
identified

Conclusion=clarifies
need for providers in
rural areas

Bias: None noted
as focus was to
gather
information

Newhouse, R. P.,
Stanik-Hutt, J.,
White, K. M.,
Johantgen, M.,
Bass, E. B.,
Zangaro, G., ...
Weiner, J. P.
(2011). Advanced
practice nurse
outcomes 19902008: A
systematic

Weaknesses=study on
based on a subset of
hospitals in each state.
No information on
turnover rates, time
needed to recruit and
long-term retention
rates. Unclear on
validity testing of tool.

No theory
identified. -

Design=Systematic
Review of published
literature between 1990
and 2008.
Method = Search strategy
of RCT between 1990 and
2008 of PubMed,
CINAHL, and Proquest
Purpose=Answer the

N = 107
Demographics
= All studies met
inclusion criteria
with at least 3
supporting
studies
Setting= All
studies were

Summary of
outcomes and
evidence for:
NP
CNS
CNM
CRNA

Systematic
Review
Utilized the
Grading of
Recommenda
tions
Assessment,
Development
, and
Evaluation

Utilized
the
Grading
of
Recomme
ndations
Assessme
nt,
Developm
ent, and
Evaluatio

APRNs when
working alone
or in
collaboration
with other
practitioners are
similar to and
sometimes
better than the
outcomes of
care provided

Feasibility=Provides
one cohorts opinion of
what is needed to recruit
providers in rural.
LOE I
Strengths= Highly
rigorous, strong
numbers, EBP focused
with highlighted quality
and safety
Weaknesses=Review
done by all nurses,
which could leave it

AAPA – American Association of Physician’s Assistants, AHRQ – Agency for Healthcare Research and Quality, APRN – Advanced Practice Registered
Nurse, AR – Arkansas, CAF – Critical Access Hospital, CEO – Chief Executive Officer, CNM – Certified Nurse Midwife, CNS – Certified Nurse Specialist,
DCE – Discrete Choice Experiment, DV – Dependent Variable, FGD – Focused Group Discussions, GPA – Grade Point Average, HPSA – Health Provider
Shortage Area, HR – Human Resources, LA – Louisiana, LOE – Level of Evidence, LPN – Licensed Practical Nurse, MS – Mississippi, PA – Physician’s
Assistant, PAEA – Physician’s Assistant Education Association, RN – Registered Nurse, SAQ – Self Administered Questionnaire, TN – Tennessee, UK –
United Kingdom, Y - Yes

GROWING RURAL APRN PROVIDERS
review. Nursing
Economics, 29(5),
1-22.

following question:
Compared to other
providers (physicians or
teams without APRNs), are
APRN patient outcomes of
care similar?

Location: USA

34
(GRADE)
Working
Group
Criteria

U.S. based.

n
(GRADE
) Working
Group
Criteria

Funding: AHRQ
Peer Reviewed=
Y

Bias: Systematic
Review and
compilation of
large amounts of
data limits
opportunity for
bias. Could be
seen as “pronursing” because
of strong
outcomes.
Mullei, K. et al.
(2010). Attracting
and retaining
health workers in
rural areas:
investigating
nurses' views on
rural posts and
policy
interventions.
Retrieved Feb 3,

Not stated,
but suggests
a focus on
value
theory –
Asks what
nurses value
in an area in
which they
choose to
work.

Design=
Non-experimental design
survey- cross-sectional
research :
Method=
Mixed method -survey
and focus group
quantitative portion (selfadministered questionnaire
– Likert scale), qualitative

by physicians
alone. Use of
CNSs in acute
care can reduce
length of stay
and cost of care
for hospitalized
patients.

open to criticism that it
contains bias
Conclusion= Very good
resource to compare
APRN practice to other
practitioners
Feasibility=Useful in
looking at how this data
can support rural
organizations recruiting
APRNs into areas that
tend to only focus on
physicians and have a
provider shortage.

N=345
Demographics
= RN students in
Africa, Split
between young
(defined as preservice) and
older more
experienced
(defined as
upgrading)
nurses going

Nonexperimental
design survey
DV1: Preservice
– average age 24,
full time on
campus students,
largely
unmarried.

SAQ tool
(selfadministered
questionnaire
) Likert. Pretested with
two
universities
not included
in study –
assessed
meanings of

SAQ
Likert
scale:
double
entered
and
verified –
Simple
descriptiv
e analysis
comparin
g

Both groups
had similar
responses to life
in rural:
Concerned with
remoteness,
lack of
resources and
poor pay.
Recommend
financial
incentives. –

LOE V: cross sectional
and qualitative
Strengths: number,
content focus,
maldistribution
challenges, randomized
Weaknesses: Location –
hard to clarify how lit
search was done and

AAPA – American Association of Physician’s Assistants, AHRQ – Agency for Healthcare Research and Quality, APRN – Advanced Practice Registered
Nurse, AR – Arkansas, CAF – Critical Access Hospital, CEO – Chief Executive Officer, CNM – Certified Nurse Midwife, CNS – Certified Nurse Specialist,
DCE – Discrete Choice Experiment, DV – Dependent Variable, FGD – Focused Group Discussions, GPA – Grade Point Average, HPSA – Health Provider
Shortage Area, HR – Human Resources, LA – Louisiana, LOE – Level of Evidence, LPN – Licensed Practical Nurse, MS – Mississippi, PA – Physician’s
Assistant, PAEA – Physician’s Assistant Education Association, RN – Registered Nurse, SAQ – Self Administered Questionnaire, TN – Tennessee, UK –
United Kingdom, Y - Yes

GROWING RURAL APRN PROVIDERS
2016, from BMC
Health Services
Research:
https://www.biom
edcentral.com/14
72-6963/10/S1/S1
Location –
Kenya, Nairobi,
S. Africa
Funding: UK
Dept. of
International
Development
Bias: None noted
as focus was to
gather
information

– (randomized focus group
interviews)
Purpose= to assess what
elements would attract new
RNs to choose to work in
rural areas versus urban
areas
Peer Reviewed = Y

35
from equivalent
of LPN to RN.
2/3 report roots
in rural, Gender:
75% female
Setting= 4
nursing schools
in rural and
urban areas in
Kenya, Nairobi,
South Africa.
Response rate=
92% preservice,
63% upgrading

DV2: Upgrading
– average age 38,
largely married,
hybrid programs.

questions and
statements.
FGD (focus
group
discussions)
– 6-8
participants
from SAQ
test group – 2
groups. 45-90
minutes

preservice
and
upgrading
.
FGD:
Principle
componen
t
analysis(P
CA) –
Cronbach’
s alpha of
0.66 then
scores
used as
dependent
variables
in
separate
linear
regression
s.
Uploaded
into
NVivo7

Lots of fear
from both
groups about
political
instability in
Kenya and
“tribal
disagreements”
–

what that showed. Not
discussed much.
Conclusion: need more
study but strengths of
working in rural include
practice scope
opportunities and low
cost of living.
Challenges = few
resources and poor
reimbursement
Feasibility: Useful as
study shows
maldistribution of
providers between rural
and urban is an
international challenge.

AAPA – American Association of Physician’s Assistants, AHRQ – Agency for Healthcare Research and Quality, APRN – Advanced Practice Registered
Nurse, AR – Arkansas, CAF – Critical Access Hospital, CEO – Chief Executive Officer, CNM – Certified Nurse Midwife, CNS – Certified Nurse Specialist,
DCE – Discrete Choice Experiment, DV – Dependent Variable, FGD – Focused Group Discussions, GPA – Grade Point Average, HPSA – Health Provider
Shortage Area, HR – Human Resources, LA – Louisiana, LOE – Level of Evidence, LPN – Licensed Practical Nurse, MS – Mississippi, PA – Physician’s
Assistant, PAEA – Physician’s Assistant Education Association, RN – Registered Nurse, SAQ – Self Administered Questionnaire, TN – Tennessee, UK –
United Kingdom, Y - Yes

GROWING RURAL APRN PROVIDERS

36
Appendix E
Synthesis Table

Author

Year Design/LOE

Setting

Population

Methods of
Recruitment

Blaaw
Odell

2010

Non-Experimental Survey/IV

Kenya, South Africa, Thailand

Nursing Students

FS, FamS, EFP, CR, RR,H

2013

Non-Experimental/V

2006

Bigbee
Glasser

2013

Qualitative Non-experimental
Research/VI
Retrospective Descriptive/IV

Rural APRNs interested in
practicing in a rural area
Rural Nurse Supervisors leading
recruitment for NHS
Rural and Urban Nursing Students

FS, EFP, CR,RR,H

Gould

Rural Mississippi Delta States: Mississippi,
Louisiana, Arkansas, Tennessee, USA
Rural
Great Britain
Rural Idaho, USA
Rural Illinois, USA

2009

Rural Wyoming, USA

Rural Hospital CEOs – survey of
provider recruitment
APRNs

FS, CR

Brown
Renner

Non-experimental
Descriptive/V
Quasi-experimental/III

2010

Non-experimental/IV

Rural Colorado, USA

MDs, APRNs, PAs

Shannon

2011

West Virginia, USA

PAs

Rural Illinois and Arkansas, USA

2011

Non-experimental
retrospective cohort/IV
Non-experimental
Descriptive/IV
Systematic Review/I

USA

Rural Hospital CEOs – survey of
provider recruitment
APRNs, MDs, PAs

FS, LR, FamS, EFP, CS, CR,
RR, H, PE
FS, LR, FamS, EFP, CS, CR,
RR, H
FS, LR, FamS, EFP, CS, CR,
RR, H, PE
N/A

2010

Non-Experimental Survey/V

Kenya, Nairobi, South Africa

Rural Nursing Students

FS, EFP, CR, RR, H

2006

MacDowell 2009
Newhouse
Mullei

FS, CS, CR, H
FS, LR,FamS, EFP,RR,PE

CR, RR

APRN – Advanced Practice Registered Nurse, CEO – Chief Executive Officer, CR – Community Resources, CS – Community Support, EFP – Extended
Family Proximity, FamS – Family Support, FS – Financial Support, H – Housing, LR – Loan Reimbursement, MD – Physician, N/A – Not Applicable, PA –
Physician’s Assistant, PE – Partner Employment, RR – Rural Roots

GROWING RURAL APRN PROVIDERS

37

Appendix F
Tyler Collaborative Model

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38
Appendix G
Survey

GROWING RURAL APRN PROVIDERS

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Appendix H

African
Asian
American
Am

Caucasian Hispanic
Figure 1

Other

GROWING RURAL APRN PROVIDERS

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Appendix I

Table 1 - Mean Scores Within Classifications

Classification

Advantage/
Challenge N

Minimum

Maximum

Advantage/
Challenge Mean
(SD)

Importance
N

Minimum

Maximum

Importance
Mean (SD)

Geographic

32

-14.00

18.00

2.41 (9.29)

29

23.00

40.00

32.21(4.00)

Economic
Management/
Decision
Making
Practice
Environment
Community
Support

20

-16.00

20.00

-0.50 (13.20)

27

27.00

40.00

32.85(4.10)

24

-16.00

20.00

4.54(11.00)

28

28.00

40.00

35.96(3.90)

33

-13.00

20.00

7.00(9.40)

33

30.00

40.00

36.90(3.15)

29

-19.00

20.00

4.55(11.39)

31

30.00

40.00

35.90(3.43)

GROWING RURAL APRN PROVIDERS

Appendix J

Figure 2 – Management and Decision Making Importance Distribution

51