Nurse practitioner Judy Vire has dedicated her life to establishing care for patients in rural parts of Central Texas. Her clinic, Kocurek & James, is one of a few providers offering medical care to communities desperate for easier access.
Vire has a master’s degree in nursing, was a nursing educator, and worked in many nursing roles, but she said her love of small-town America and the people there inspires her life’s work.
Daily Nurse proudly names Judy Vire the Nurse of the Week for her dedication to providing access to care to small-town and rural communities and caring for the most vulnerable patients, those who are unable to leave their homes.
Vire and her family settled in Flatonia, where she helped open the Rural Health Clinic in Flatonia and Schulenberg. Medical care is paramount for people in this rural part of Central Texas.
“It’s critical. Without having access to care close to home, people would be commuting into Austin, Katy, Victoria — that’s at least an hour’s drive any way you go,” Vire says. “These small communities depend on having these home-grown clinics close to home for convenience and access to care.”
Vire often makes house calls to the most vulnerable patients who cannot leave their homes.
“Because it’s a rural area, we serve an older population. The 65 and older are our largest population, and they, of course, need the most care,” Vire explains.
Regardless of whether a patient is old or young, Vire believes establishing trust is most important.
“Healthcare is personal. And when you have to tell someone bad news that impacts their lives, that is very personal, and people let you do that and trust you to do that,” she says.
That trust, she says, is why she’s given over 40 years to this career. Throughout her time at the Schulenberg clinic, she has seen generations of families making a daily impact on these communities.
In 2003, Vire was named Nurse Practitioner of the Year, and this year, she’s a Remarkable Woman nominee.
“It feels wonderful, and I was very surprised because there are a whole lot of more remarkable women than myself,” she says.
When asked about her most treasured career accomplishment at this clinic, she said it’s time.
“Maybe it’s longevity,” Vire says. “I can’t believe it’s been 30-some-odd years, and I am still doing this. I am proud of that.”
Nominate a Nurse of the Week! Every Wednesday, DailyNurse.com features a nurse making a difference in the lives of their patients, students, and colleagues. We encourage you to nominate a nurse who has impacted your life as the next Nurse of the Week, and we’ll feature them online and in our weekly newsletter.
We’ve all heard the statistics about the growing need for trained healthcare professionals, especially nurses, within our society. Federal estimates indicate that not nearly enough people are entering the field to meet the projected healthcare needs of the coming decades.
Although the overall need is concerning, the issue is particularly acute in rural communities. Here, staffing shortages have caused the closure of entire wards of hospitals, forcing rural community members to travel great distances to seek healthcare treatment.
Rural nurses’ challenges can be profound, especially within the current system. Fortunately, new technologies are being incorporated to relieve some stresses and provide greater opportunities. Becoming a rural nurse comes with its real challenges, but these tech advancements could help make it a more rewarding decision.
Challenges Facing Rural Hospitals
Rural communities have experienced a sharp decline in economic output over the years. Over the past few decades, demographic trends in the United States have indicated that people are leaving rural areas and heading for the city in droves. The primary reason for this is the pursuit of better economic opportunities.
Healthcare services have not been excluded from this mass exodus from rural communities. Today, workforce shortages are common in rural hospitals, and many nurses choose to live and work in cities where higher pay and more amenities are available. This ultimately means that remaining rural nurses are spread thin and asked to treat a greater variety of ailments. Because rural communities are often lower-income, salaries are also lower for healthcare providers.
All of this has a significant impact on community members, too. Much research indicates that rural communities have more chronic conditions and poorer health outcomes. This can be attributed to several reasons, including fewer opportunities for local specialized care and economic factors that play into the ability to seek the right treatment elsewhere.
Fortunately, technological advancements are alleviating some issues associated with obtaining necessary healthcare in a rural setting. The most important of these advancements is within the realm of telehealth. Telehealth services allow rural residents to “see” specialists and other healthcare providers from the comfort of their own homes or their local clinic.
Initial consultation appointments, examinations, post-treatment follow-up appointments, and rehab can be conducted online. All of which can save multiple trips to an urban center and thousands of dollars. Many health conditions can be treated via telehealth services, including things like:
Skin conditions;
Prescriptions and associated refills;
Allergy assessments;
Asthma treatments;
Mental health examinations and therapy;
Follow-up visits for hearing and visual healthcare;
Physical therapy and other forms of rehab;
Diabetes management and prevention;
Some forms of addiction treatment.
Rural nurses have a profound ability to play a critical role in their community healthcare as telemedicine becomes more mainstream. For one, nurses can be essential resources for urban doctors following up with their rural patients. These nurses can help reinforce treatment recommendations and ensure that patients fully understand the information communicated online.
As a rural community member, locals will trust you more than the urban doctors they speak with online. Rural communities are often very tight-knit, and the nurses within them are valued and trusted resources. This puts all rural nurses at the forefront of encouraging telehealth adoption and could make a profound difference in community healthcare outcomes.
Things to Consider Before Moving
Deciding to become a nurse in a rural area can be a challenging one. You may have wanted to return to your small town and make a difference in your local community, or you may be considering a rural lifestyle for yourself and your family. There are significant challenges working in a rural healthcare setting, but also several profound benefits and rewarding experiences.
One thing to consider is that many federal and state programs offer incentives for trained professionals to bring their skills to live and work in rural settings. For instance, some areas provide financial bonuses comparable to urban salaries to help bring healthcare professionals in. Others offer student loan forgiveness programs where nurses work for many years in a rural setting, and all of their loans are forgiven.
In some cases, a greater degree of autonomy is provided to rural nurses and other healthcare providers. Many nurse practitioners in rural settings have reported that they feel more able to practice to the full legal scope of their training. In contrast, in more urban settings, many have reported feeling they are still required to clear every decision with a doctor. Numerous bills in Congress seek to help loosen some restrictions that will make nurses more capable of providing services without direct doctor supervision.
It’s up to you to decide if the benefits of rural healthcare outweigh the challenges. If you choose to move, you must take extra time to account for these challenges.
When listening to stories about the nationwide nursing shortage, some of us might immediately think of urban hospitals as the overwhelmed facilities most acutely struggling to care for the citizens of densely populated metropolitan areas. There are approximately 20 million people in the larger New York City region, and Los Angeles and Houston have more than 12 million and 7 million, respectively. That’s certainly a lot of people to care for.
However, the reality is that the shortage of qualified nursing professionals is in no way confined to the cities. Rural communities are also suffering, and the need for action is paramount.
Rural Healthcare on the Edge
According to a May 2023 article in the journal Chief Healthcare Executive, 35% of the hospitals in the U.S. can be categorized as rural, and more than 600 are at risk of closure. The consequences could be severe in Pennsylvania, Missouri, and many other states with large rural populations, and anyone aware of the situation is justifiably concerned.
While urban hospitals can often choose to close units or shutter a percentage of beds due to plenty of nearby hospitals picking up the slack, many rural hospitals serve as a medical safety net for large geographic areas and can’t simply decrease capacity. If your hospital is an oasis in a medical desert, it’s a serious responsibility to remain open and accessible.
Meanwhile, recruiting doctors, nurses, and other professional staff to live and work in rural areas can be challenging, especially when younger clinicians are more likely to prefer to settle in urban centers offering more nightlife, professional opportunities, social outlets, and cultural amenities.
At the same time, the American Association of Colleges of Nursing has reported that nursing school enrollment has fallen in recent years, with entry-level baccalaureate nursing programs losing 1.4% in 2022, MSN programs dropping 9.4% since 2021, and PhD programs shrinking by 4.1% from 2021 to 2022. With tens of thousands of qualified candidates turned away each year due to a lack of faculty and appropriate clinical training sites, this decreased nursing school capacity feeds directly into hobbled patient care capacity at urban and rural levels.
The Rural Health Information Hub (RHIhub) reports that the use of methamphetamine and tobacco is higher in rural adults than in their urban counterparts, and rural teens are much more likely than urban adolescents to abuse alcohol and drive while under the influence.
With overdose deaths disproportionately higher in rural areas, the repercussions of such dire statistics don’t bode well in areas already lacking sufficient healthcare resources, including clinician shortages and facilities at risk of being permanently shuttered.
Solutions Are Needed
Considering that 35% of American hospitals are in rural areas and that substance use disorders and other ills plague rural communities as much as, or more than, urban centers, action is needed to stem the tide.
Increasing nursing school capacity across the country is a prudent course of action to begin to solve the nursing shortage. And if we can find solutions to the astronomical debt (often more than $250,000 to $300,000) taken on by medical students while completing their studies and becoming physicians.
One thing that some rural communities may have going for them is significantly lower housing costs and a lower cost of living, something that newly debt-saddled physicians (and nurses) should take into consideration. Despite relatively lower salaries, rural living can counterbalance a more straightforward way of life and more affordability. Any way that we can mitigate rural workforce deficits is vital to consider.
Tulane University suggests increased access to mobile health clinics, telehealth, and rural-urban collaborations that leverage the technology and capacity of healthcare systems in large population centers. Reliable broadband service is crucial to rural patients being able to make use of telehealth and app-based care solutions.
Infrastructure for healthcare-related transportation could be critical in some rural areas where elderly or poor residents face barriers of distance and cost when attending medical appointments. From oral health and preventive care to home health and hospice, patients can only receive care when it is accessible and affordable and has adequate staff to meet patients’ needs.
Urban, suburban, and rural health are all equally important in terms of the overall health of our society. Rural areas need nurses, physicians, and other allied professionals willing to dedicate themselves to the issues faced by those outside of major cities and towns. Advocacy, collaboration, and creative thinking are pillars upon which effective strategies can be built, and nurses can be at the forefront of how these deficits and challenges are thoughtfully addressed.
While the average person probably thinks that nurses working via telehealth is something new that came about during COVID, that couldn’t be further from the truth.
“I have personally been practicing in telehealth for the past eight years,” says Mariea Snell, DNP, APRN, FNP-C, an associate professor of nursing and the director of the Doctor of Nursing Practice Programs at Maryville University. “I think the pandemic changes how people access care in large numbers, but it is not new. Many people with access issues due to physical disabilities or needs have used these systems. Others did not fully understand what it could do until put to the test.”
Georgia Reiner, MS CPHRM, a Risk Analyst at the Nurses Service Organization (NSO), agrees that telehealth has been around for a while. She adds, though, that its use has dramatically increased.
“Some nursing professionals, mainly advanced practice registered nurses (APRNs), including nurse practitioners (NPs), worked in telehealth before the beginning of the pandemic. However, there has been a dramatic increase in the utilization and availability of telehealth services due to policy changes implemented in response to the COVID pandemic,” says Reiner. “For example, an analysis by McKinsey & Co found that telehealth accounted for less than 1% of Medicare services before the onset of the pandemic, but by July of 2021, telehealth services accounted for about 13-17% of claims submitted to Medicare. Additionally, licensing requirements were relaxed in many states, which helped enable nursing professionals to practice across state lines via telehealth, as were requirements that patients have an established relationship with a provider before they could receive telehealth services. However, many of those policy changes are set to expire at the end of the public health emergency, leaving the future of telehealth services somewhat in question.”
Additional Training
If you’ve never worked in telehealth before, you may wonder if it’s necessary to receive additional training before working in it. The answer is yes and no.
“All nurses can participate in telehealth,” says Snell. “They would provide the level of care that each are currently licensed to provide. In the case of a DNP/NP, they would treat patients the same way they would in an office setting.”
However, the training that nurses would and could receive will depend on several factors.
“Nurses and advanced practice registered nurses may receive training through their educational programs on the use of telehealth. If nurses do not receive this training in their educational preparation, they may receive it through their employment or workshops and educational programs. There are certification courses that are available for healthcare providers to take as well,” explains Robin Arends, DNP, CNP, FNP-BC, PMHNP-CE, CNE, FAAN, FAANP, the APRN Program Director at South Dakota State University as well as a nurse practitioner at Avel eCare. She’s published and presented both workshops and talks about all aspects of telehealth—regionally, nationally, and internationally.
Nurses have worked in a variety of settings in telehealth—such as school nursing, critical care, emergency care, specialty care, and geriatrics, Arends says. Be sure to check if the state you’re practicing in mandates training or taking a test before providing telehealth services.
She continues: “Nurses should be trained to use the telehealth equipment to complete the assessment and how to help others at a remote location use the equipment. They should understand how to appear on camera and communicate with patients through technology. Nurses should be aware of the background that the patient sees on camera and any sounds occurring in their environment. Nurses must know and comply with HIPAA, information security, and confidentiality. Nurses should also be aware of licensing requirements as they need to be licensed in the state where the patient is located.”
Because she works as a risk analyst, Reiner takes a deeper dive when explaining the training nurses need and why.
“Nursing professionals working in telehealth need to verify with relevant state professional licensing boards the practitioners — known as “qualified providers” — who can legally provide telehealth services. Nurses must be appropriately credentialed to practice in the state(s) where their patients or clients are located and work under that state’s scope of practice for nursing professionals,” Reiner says.
“Prior to beginning any telehealth work, nurses need to be prepared and have a backup plan in place in case of an emergency or technology breakdown. In addition to obtaining their patient’s/client’s consent before participating in telehealth services, nurses must also clearly convey to their patients/clients the inherent technical and operational hazards that may impede communication, such as:
System compromise or hardware failure, which could lead to an incomplete or failed transmissions.
File corruption or other data transmission issues, resulting in less than complete, unclear, or inaccurate reception of information or images.
Unauthorized third-party access, which may lead to data integrity or information security problems.
Natural disasters, such as hurricanes, tornadoes, and floods, which can potentially interrupt operations and compromise computer networks.
Whether a nurse can or should provide telehealth services from their residence depends on factors including state regulations, their employer’s policies, and procedures, their home environment and infrastructure, their ability to comply with technical, security, and confidentiality considerations from their home, as well as the nurse’s comfort level with engaging in telehealth practice from their home.”
Challenges
Working in telehealth may seem much easier because it can be done from nearly anywhere. However, there are some challenges to working in it.
“The biggest challenge is that providing services via telehealth is so different from traditional, in-person care, where a patient is physically present in front of the nurse. When providing telehealth services, the nurse relies entirely on technology for the patient encounter. In addition to adhering to traditional clinical standards of care and practicing within the scope of practice authorized by law, there are also technical considerations,” says Reiner. “Equipment and software must be routinely tested, maintained, and updated for quality assurance. Nursing professionals and their employers must also track how well a telehealth program functions carefully. Indicators should capture clinical, efficiency, and satisfaction outcomes, including:
Patient/client complication and morbidity rates
Compliance with provider performance criteria
Diagnostic accuracy
Adherence to clinical protocols
Referral rates
Patient/client satisfaction levels
Cost per case
Delays in accessing consultations, referrals, or specialty practitioners
Arends says that another challenge is that nurses must remember to maintain licenses in the states where their patients are located—and follow that state’s practice rules and regulations.
Remember Documentation
Just as you would if seeing a patient in person, nurses need to do documentation.
“Telehealth sessions should be as thoroughly documented as all other patient/client encounters. Just because some information may be automatically captured by software doesn’t negate the nurse’s professional responsibilities around documentation,” Reiner states. “Documentation in the patient’s medical record should be in accordance with the same documentation standards of in-person visits—including documentation of all communications with the patient or other providers (whether verbal, audiovisual, or written), clinical observations, orders, test results, and patient education and follow-up instructions.”
Telehealth Helps Nurses Become a Key Player
According to our sources, if you haven’t decided whether to look into providing telehealth, you should.
“Nurses should consider getting into telehealth because this is the direction that healthcare is going in. Incorporating technology in care will continue to develop and will never go back,” says Snell. “It is important to stay current with this trend. You won’t necessarily make more money, but you will be more marketable and have a better work-life balance.”
Arends agrees. “Nurses should consider working in telehealth because there are increasing opportunities in this area of healthcare. Patients saw the benefit of telehealth during COVID and want to continue to receive healthcare through this modality. Telehealth has shown high patient and provider satisfaction. I predict that telehealth will only continue to grow and expand.”
In addition, Arends believes that nurses will become key players in telehealth. “Nurses are the core of healthcare. In traditional settings such as hospitals, they are the first to alert providers to changes in the patient’s condition and are truly the front lines of healthcare. This will continue to be seen in telehealth,” she says. “Many studies have shown that nurses utilizing telehealth for remote monitoring as well as real-time audio video telehealth formats have reduced complications and readmissions and increased access to care.”
The benefits to patients are seemingly endless. “Nurses work where the patients are. Some patients cannot travel to clinics because of weather, physical condition, or other factors. Nurses who work in telehealth can care for patients when the patients are not able to seek care from traditional locations. Like home visits, nurses can visit the patients in their home environment. They can assess how the patient moves and works in their environment. They can assess for safety hazards in the home environment as well.”
Finally, working as a nurse with patients in telehealth can also be immensely rewarding. “The greatest award of working in telehealth is helping the patient achieve the best health outcomes while minimizing barriers to accessing healthcare,” says Arends. “Helping a patient who may not be able to access healthcare for various reasons achieve control of chronic diseases or feel healthier is a huge reward for telehealth. In addition, helping patients meet their personal care goals in their preferred environment is also optimal.”
The “Save America’s Rural Hospitals Act” (H.R. 833) was reintroduced by Congress in late February. Along with providing enhanced payments to rural healthcare providers to help ensure the viability of these important local healthcare facilities, this legislation also includes a provision to permanently remove physician supervision of Certified Registered Nurse Anesthetists (CRNAs) under Medicare Part A conditions of participation and a provision to include non-medically directed CRNA services as a mandatory benefit under the Medicaid program.
CRNAs have practiced without this regulation for nearly three years under healthcare flexibilities issued during the public health emergency.
Today more than ever, rural communities must address accessibility issues, including a lack of healthcare providers, the needs of an aging population suffering from more chronic conditions, access to healthcare, and larger percentages of uninsured and underinsured citizens,” says AANA President Angela Mund, DNP, CRNA. “As a CRNA who grew up in a small town in far northwestern Minnesota, I know firsthand the challenges of recruiting healthcare providers and how important the solo CRNA was to ensure that we could provide surgical services to our community. The ‘Save America’s Rural Hospitals Act’ comes at a time when rural hospitals and health centers face unprecedented challenges and struggle to keep their lights on and serve their communities.”
According to the National Rural Health Association, more than 170 rural hospitals across the country have closed their doors since 2005, and 453 rural hospitals are currently operating at levels similar to those that have shut down during the last decade, meaning they are vulnerable to closure. This forces patients to travel further to get the care they need and leaves others to put off necessary healthcare.
In November 2020, during the surge of COVID-19 in rural America, AANA joined several other healthcare organizations to bring equitable access to care in rural America and bridge the rural divide. The Rural Health Action Alliance (RHAA), a coalition of healthcare providers and facilities that provide high-quality, evidence-based care to millions of Americans, seeks to advance federal policies to improve rural health outcomes.
“CRNAs are the primary providers of anesthesia care in rural settings and have been instrumental in delivering care during the pandemic to patients where they live and when they need it,” says Mund. “Often, CRNAs serve as the sole anesthesia provider in rural hospitals, affording these facilities the capability to provide many necessary procedures.”
The importance of CRNA services in rural areas was highlighted in a recent survey that examined the relationship between socioeconomic factors related to geography and insurance type and the distribution of anesthesia provider type.
The study correlated CRNA services with lower-income populations and correlated anesthesiologist services with higher-income populations. Of importance to implementing public benefit programs in the U.S., the study also showed that compared with anesthesiologists, CRNAs are more likely to work in areas with lower median incomes and larger populations of citizens who are unemployed, uninsured and/or Medicaid beneficiaries.
More information and the opportunity to contact your local U.S. Representative on this issue are available here.
The $125 million donation by Leonard A. Lauder, Chairman Emeritus of The Estee Lauder Companies, to create this first-of-its-kind, tuition-free Program is the largest gift ever to an American nursing school. Mr. Lauder is a Penn alumnus. The gift comes at a time when the COVID-19 pandemic has magnified the nation’s acute shortage of primary care providers, and persisting inequities in access to quality healthcare.
“This is the most timely and consequential gift not only for our university but for our country. It is unprecedented in its potential to address America’s most critical need of providing primary health care to all who currently lack it by investing in nurses,” said former Penn President Amy Gutmann.
“Growing the number of nurse practitioners who are prepared and committed to working in underserved areas is the most practical and inspiring way to ensuring a healthier country. I am grateful and honored that Leonard would make this gift to Penn Nursing, and thrilled to know that it will have an immediate impact that will last far into the future.”
Nurse practitioners are leaders on the front lines of care, a role never more important as Americans confront a primary healthcare shortage in their communities. With their advanced clinical training and graduate education, nurse practitioners have the knowledge and skill to supervise and manage critical aspects of care in a decision-making capacity, from patient diagnosis, to ordering and interpreting tests, to prescribing medication. Nurse practitioners deliver high-quality primary care to people of all ages, such as treating common illnesses, managing chronic conditions, and providing preventive care that helps patients stay healthy.
Nurse practitioners are also able to take on key leadership roles, from managing and operating walk-in or community clinics to leading interdisciplinary teams within health systems. The new Program will better the lives of patients and communities most in need, while providing a pathway for the many nurses interested in advanced education who may not otherwise have the means to pursue it.
The Program
Structure: Leonard A. Lauder Community Care Nurse Practitioner Fellows will enroll full-time in a two-year, rigorous Primary Care Nurse Practitioner Program at Penn Nursing.
Community Practice: Fellows will complete at least 50 percent of their clinical education at community partner sites in the greater Philadelphia area that provide direct patient care, an invaluable experience that will prepare Fellows to meet the complex needs of patients and families throughout their careers. Every Fellow will be expected to commit to practice or service in an underserved community for two years after graduation.
Recruitment: Penn Nursing will select 10 Fellows to begin classes this fall, growing the program enrollment through 2026 when it will reach its annual target enrollment of 40 Fellows, continuing in perpetuity. By 2027, the program will have enrolled 140 excellent nurse practitioner students. Fellows will need to show a demonstrated commitment to working in underserved neighborhoods, where they are needed most, and to promoting health equity.
Tuition: All participants in the program will enter the workforce free of graduate school debt, receiving student aid to cover their tuition and fees and thereby eliminating any potential financial barriers for nurses and others who wish to enroll. Fellows with greater financial need will also receive stipends to help with living expenses.
Program Leadership: Penn Nursing will name the first endowed Leonard A. Lauder Community Care Nurse Practitioner Professor, who will oversee curriculum innovation, support of community sites, and program implementation.
Penn Community Partnership: Penn Nursing will provide support for select community partner sites to support the clinical education of Fellows while providing professional development and networking opportunities and access to School and University resources.
“Penn Nursing has a long history of advancing science, promoting equity, practice excellence, and preparing leaders. That’s why Mr. Lauder’s gift is so meaningful. The synergy between Penn Nursing and the Program will improve the health of underserved patients and families, by uniquely preparing primary care nurse practitioners, who will work with them in their communities. The sustained investment in the education and careers of primary care nurse practitioners and communities is unprecedented. We are excited by the opportunity to lead this important Program and to extend its impact beyond Penn Nursing,” says Penn Nursing Dean Antonia Villarruel. “We are deeply grateful to Mr. Lauder for recognizing and investing in this critical need, and for partnering with us in this ambitious endeavor.”
NPs are “key” to health care in underserved communities
Stephen P. Fera, Executive Vice President of Independence Blue Cross, which is one of the community partners that will be involved in the new initiative, noted that nurse practitioners are key to improving individual and community care. Said Fera: “Bolstering the nurse practitioner workforce is a means to improve access to care and strengthen the health care safety net provided by health centers. This is a key priority of the Independence Blue Cross Foundation and our partnership with Penn Nursing has been synergistic in efforts to prepare nurses to work in community-based settings. The Program will build and strengthen our individual and collective efforts toward improving the health and well-being of communities.”
“Now more than ever, the country needs greater and more equitable access to quality primary care—and highly-skilled nurse practitioners are the key to making that happen,” said Leonard A. Lauder. “The program will ensure that more Americans receive the essential health care services that everyone deserves, and I’m so pleased to be working with Penn Nursing on this initiative. I look forward to welcoming our first class of future nurse practitioners this fall. I know their expertise will be matched only by their commitment to serving our communities.”
