PARK RAPIDS, Minn. -- A nurse practitioner who works part-time at Essentia Health-Park Rapids Clinic is part of a residency program to help new graduates transition to rural health care careers.
Kelsey Stay works mainly at Essentia’s Walker Clinic, but also sees walk-in patients in Park Rapids, mainly on weekends. She started the job in April after graduating in May 2020 from the College of St. Scholastica in Duluth with a Doctor of Nursing Practice degree.
Since October, Stay has also been one of four nurse practitioners (NP) across the Essentia Health system participating in a 12-month residency program, in partnership with North Dakota State University.
For Essentia, it’s an extension of the health system’s Transition to Practice program, which helps new NPs and physician assistants make the adjustment from classroom to clinical practice.
“As a new grad, I feel like it’s a very overwhelming process for a nurse practitioner to go from school to like, ‘All right, here’s your patients,’” said Stay. “Most nurse practitioners start as nurses, and you’re used to having almost a menu of – ‘OK, your patient has pain. Here’s your choices of medication; here’s your choices of dosages.’ Now, as a nurse practitioner, you’re the one making that menu.”
In response to this, Stay said, “Essentia has been so incredibly supportive with this onboarding system.”
It includes regular check-ins with an experienced NP in Fargo, doctors at the Walker clinic, and her own assigned mentor.
“I’ve never felt so supported, jumping into a new role before. It’s wonderful,” said Stay. “You can go to anyone with questions. Everyone’s willing to help.”
Focus on rural
Added to that is the residency program, funded through the NDSU School of Nursing, which received a four-year, $1.575 million Advance Nursing Education Nurse Practitioner Residency Grant three years ago through the Health Resources Services Administration.
Dr. Mykell Barnacle, program director of the residency program and a faculty member at NDSU school of nursing DNP program, said it doesn’t matter whether the residents are NDSU graduates; in fact, none of this year’s NP residents are.
Barnacle said they decided at the outset to partner exclusively with the Essentia Health system as part of the school’s emphasis on rural health care.
“We wanted to work with one specific organization to make the opportunities more seamless,” said Dr. Dean Gross, program coordinator of the residency program and director of NDSU’s NP program. “It also eliminated us from the selection process” – that is, Essentia chooses the candidates.
During the past decade, Gross and Barnacle have worked to change the mission of NDSU’s nursing school to emphasize rural practice.
“We found that unless an individual was born in a rural community and had family there, they didn’t really return there unless they were exposed to that rural community,” said Gross. “We’ve been working together to promote our nurse practitioners to go to the rural area and have their clinical rotations there.”
More supports needed
Barnacle said the school recognizes the complexity of the NP’s role and the difficulty of transitioning to a rural area, where a new graduate may not have as many supports to fall back on as in an urban clinic.
“It is a big transition anywhere,” she said. “There’s a lot of responsibility, certainly, with the role transition from a student to a provider.”
That’s especially true in rural areas, Barnacle noted. “Typically, rural providers have a very broad scope of practice, and so they care for people that would maybe be sent to a specialist in a more urban area. They do a lot more procedures than individuals in urban areas do.”
For example, rural patients may not want to travel two hours to have a toenail removed. “It really becomes a customer service issue,” said Barnacle. So, instead of sending them to a specialist, rural NPs must develop a wider range of skills.
Through the residency program, NDSU provides education, such as a two-day procedural workshop in Baxter where “they do everything from splinting to advanced suture techniques and, as I said, toenail removal,” Barnacle said.
They also have an in-person emergency preparedness simulation and other day-long, hands-on activities, plus virtual meetings and webinars. The grant also covers residents’ travel expenses to clinical rotations in specialty practices.
For example, Stay has a rotation in the radiology department in December in Detroit Lakes, and looks forward to a pediatrics rotation in January at the Park Rapids clinic.
“This past month, there was educational training on sleep medicine,” she said. “We covered topics on lab values and pulmonary function tests.”
Improving the outcome
Though she just started her residency in October, Stay said it’s already been great, allowing her to connect with the three other residents – two in Detroit Lakes and one in Hibbing – and bounce ideas off them.
It also connects her with providers across the Essentia system, in case she has questions. “Just being able to pick the brains of people that work in specialties,” she said, allows her “as a family practice provider to have some better insight with those specialties. … I think it helps establish a good working relationship with these people as well.”
“We have a huge health system, but you feel kind of alone, rural,” said Christie Erickson, an NP and director of Essentia’s Transition to Practice program. “Once you connect with all these other people, suddenly you don’t feel like you’re quite so alone.”
Prior to starting this onboarding program, Erickson said, Essentia had an 18% annual turnover of NPs, but it’s now down to about 5% – despite the higher level of stress for health care providers due with the COVID-19 pandemic.
The numbers speak for themselves. During the first two years of the current grant, Gross said, “We’ve had eight residents complete the program, and all eight have been retained in the rural clinics where they were hired … an amazing, 100% retention rate.”
War of attrition
“The supports that folks need as health care providers, especially in our rural communities – I think it’s needed now more than ever,” Erickson said. “They’re having difficult conversations with patients on a regular basis about health care in general, but with the pandemic … about immunizations and COVID, immunization hesitancy and concerns about treatments and precautions that need to be taken.”
Barnacle added that the stressors from the pandemic include the sheer number of patients to care for, many of them doing poorly or dying. “I think that it has been emotionally draining,” she said.
Gross said some nurses may have left the profession during the pandemic due to the stress of pulling double and triple shifts. However, this has opened up many opportunities for new nursing graduates.
“There’s a perception, nationally, that there’s a shortage of nurse practitioners in the rural area,” said Gross. “We haven’t felt that in the past two years because of COVID and institutions downsizing the number of advanced practice providers. But Essentia is moving ahead with a lot of rural nurse practitioners in the very near future to address that.”
The residency program helps Essentia’s new NPs feel competent and confident as they progress in their career, said Erickson, by showing them that they have the support they need and colleagues to connect with.
Besides all the connections the programs makes to help Stay close gaps in her clinical knowledge, it also plugs her into a network of contacts who can provide even more resources, as well as three fellow residents who understand just what she’s going through. It’s “a wonderful network of support on every level,” she said.
“We went into this not sure what would be the outcome,” said Gross. “But after the first couple of years, we noted significant improvement, because we were careful to elicit information from the participants, the residents and their managers, about what they need to be successful out there.”
He said their feedback has even led to improvements in their school’s NP degree program.
“This has been transformational for us,” said Gross. “We’re able to implement more rural expectations, which translates well to any primary care environment.”