A rural outreach

Improving rural health is a focus of USC's College of Nursing

Residents in rural South Carolina are more likely to be hospitalized for and die from certain health conditions, including congestive heart failure, cancer, diabetes and stroke. Improving rural health is a key focus for USC’s College of Nursing, which has initiatives in place to address rural health disparities, improve mental health access and respect cultural differences in health care decision making.

Staying local

As a native of the area, Leigh Pate knew what she was getting into when she started working at the Community Medical Clinic of Kershaw County in Camden. Most of her patients don’t have transportation, health insurance or the means to pay.

“I grew up in a rural area and understand the limited access to care,” says Pate, who is also a College of Nursing clinical instructor teaching USC Lancaster students. Her students volunteer at the Community Medical Clinic, and many of them have similar insight to the challenges facing rural residents.

Many of Pate’s clients are dealing with high blood pressure, diabetes or being overweight — prevalent conditions that are treatable without hospitalization.
Clinic staff members work to keep patients out of emergency rooms for non-life threatening ailments. 

When it began in 1998, the free clinic operated one day per week, but soon expanded to four. Now the clinic, run almost entirely by nurse practitioners, offers medical services at North Central middle and high schools and at four satelitte sites in Kershaw County.

Pate sees the work at the clinic as an extension of her nursing classes. She recalls discussing lab results with one patient: “The woman said, ‘You’re the first person to explain it in a way that I actually understand,’” Pate says. Educating patients on how to manage chronic illnesses such as diabetes is a large portion of the nurse practitioners’ job. 

“Every time I go to work, I know that I’m helping people,” Pate says. It’s that interaction with patients that convinced her to go back and earn B.S.N. and M.S.N. degrees after getting a bachelor’s in healthcare management at Winthrop University. Pate is now working on her nursing doctorate, which she hopes to finish next spring.

“You make a huge difference by being an educator,” says Pate, who hopes to inspire her students to help their community. “Our students are staying local after graduation.”

The Promise Zone

USC’s College of Nursing is part of a collaborative effort among government agencies and nonprofit organizations to improve health care in Allendale, Bamberg, Barnwell, Colleton, Hampton and Jasper counties. The six rural counties, among the state’s poorest, were designated by the federal government as a Promise Zone to increase federal assistance in that region.
To that end, the U.S. Department of Health and Human Services recently awarded the College of Nursing a nearly $1 million grant to increase the number of nurse practitioners in the six-county area. The grant will pay for training 30 new family nurse practitioners a year for two years.

“Research demonstrates that nurse practitioners are safe, autonomous providers who demonstrate excellent patient outcomes, high patient satisfaction and increase access to care,” says Stephanie Burgess, the college’s associate dean for practice.

Eighty percent of the family nurse practitioner students selected for the funding will be low-income, first-generation “Promise Zone” residents or part of an underrepresented population in the nursing ranks.

Students will do clinical training at mental health facilities, primary care and women’s health clinics, federally qualified health care centers, rural health centers, free clinics, migrant clinics and private primary care practices. Half of the students are expected to work in rural areas within six months of graduation.

The college also received a grant to increase the number of doctoral students from the designated Promise Zone as a way to help address the nursing faculty shortage in the United States.

Cultural sensitivities

The most difficult conversations a health care professional will ever have involve giving a patient a terminal prognosis. One of the most thorough studies of end-of-life communications was undertaken by USC nursing professor Ronit Elk.

Over a two-year period, Elk worked with older rural Southerners, black and white, in Beaufort County, S.C. Elk’s team conducted focus groups with people who had recently lost a relative or loved one, and from those discussions came a list of themes about how they thought health care professionals performed and what could be done better.

Elk’s team then met with a diverse group of community advisory board members who examined the themes from their own cultural perspectives and shared their community’s preferences for how certain situations should be handled by health care professionals.

Key differences were noted about terminal prognoses. “Doctors think, ‘I should tell my patient that they have only two weeks left to live so they can get their affairs in order and say goodbye,’” Elk says. “Yet in the African-American community, the belief in hope is extremely strong and a very important concept. The miracle that can happen — that God can bring about — that is always a factor.”

Another difference is in enabling patients to make their own decisions. “But this practice is based very much on the white middle-class model in which patient empowerment, individual decision-making, is highly valued,” Elk says. “Yet, this does not fit with the African-American community model in which families make shared decisions, especially in such circumstances.”
The protocol was completed, then field-tested at Beaufort Memorial Hospital. The palliative care physician followed all of the community’s recommendations.

Such community-based participatory research provides a way to partner respectfully with a community, Elk says, and the method has proven successful in reducing racial disparities in health outcomes.

“If you’re going to do a program that will affect a certain group, wouldn’t you want to consult that community?” Elk says. “That’s the heart of communication.”

A virtual presence

As director of the College of Nursing’s psychiatric mental health nurse practitioner program, Tena McKinney oversees an interdisciplinary educational program for teams of graduate nursing students, Master of Social Work students and graduate pharmacy students who use telehealth technology to consult with patients.

“There’s a gap in mental health between being OK and being in the emergency room — those are the clients we’re addressing,” says McKinney, who also is a clinical associate professor of nursing.

“Rural providers don’t have many resources, so we beam in, talk to clients and make recommendations for treatment.
We also provide a list of behavioral things a patient needs to be coached on and what resources are available in that area.”

McKinney’s project, funded by the Duke Endowment, trains students to work in interprofessional teams while getting experience in both mental health treatment and telehealth technology.

“Telehealth takes a bit of getting used to, especially if you’re accustomed to using therapeutic touch. If the patient starts crying, you can touch without saying anything,” says Danielle Simmons, a mental health nurse practitioner student. “In telehealth, I would say, ‘I see you’re upset, can you tell me what you’re feeling? Tell me the best you can, I don’t care what words you use.’”

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