Redefining the nursing shortage: A rural perspective

Redefining the Nursing Shortage: A Rural Perspective Terry D. Stratton, MA Jeri W. Dunkin, PhD, RN Nyla Juhl, PhD, RN

Many rural areas in the United States face a legitimate shortage of nurses.

W

hile the nursing shortage has reportedly subsided in parts of the United States, 1,2 many continue to view the situation with cautious skepticism, worried that recent gains may be little more than a remission. 3-5 Some have argued that as long as the trend toward higher skill levels continues, 6-9 the corresponding demand for nursing services within the health care system will inevitably escalate faster than the supply, ensuring that some level of shortage will always exist, l°

The nursing shortage occurred at a time when the number of nurses entering the field had not appreciably declined. This debate has been fueled by dissention over both conceptual and methodologic issues. For instance, the lack of any consistent conceptualization of a nursing "shortage" has been pup NURSOUTLOOK1995;43:71-7. Copyright ©

1995 by Mosby-Year Book, Inc. 0029-6554/95/$3.00 + 0 3 5 / 1 / 5 6 2 2 2

ported to be a primary cause of the widespread dissent and confusionJ 1 Out of this lack of standardization has emerged any number of distinct versions of "reality," each based on a particular vantage point. Methodologically, this lack of conceptualization has resulted in a myriad of operational definitions, employing any number of approaches to systematically determine what level of shortage exists, based on the particular criteria used. lzq5 THE ASSESSMENTS Although some scholars write with an air of inevitability about the shortage of nurses in the American health care system, 1° others have analyzed the shortage from a much less problematic standpoint. Characteristic of such analyses have been recommendations that educational programs become more responsive to the changing roles of nurses, focusing on producing appropriate types of nurses, rather than simply m o r e nurses. 16,17 Others have contended that serious thought must be directed toward restructuring the ways in which nurses are being put to use by the health care system. 12, 13, 18 Aside from some regional and professional variations, the nursing shortage occurred at a time when the number of nurses entering the field had not appreciably declined) 9 Reflecting the many uncertainties that continue to

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complicate the issue, however, considerable debate exists about the current supply of nurses. 8, 17,20-21 According to Ritter, al two underlying factors that have contributed to this ambiguity have been a lack of adequate resources to compile and maintain nursingrelated databases and the use of nonstandardized reporting methods, both of which have placed stringent limitations on the accuracy and availability of even the most basic nursing data. Moreover, even when consistent data are available, conclusions that are drawn often reflect considerable disagreement. 22

Many scholars have agreed that any shortage is largely a function of changes in utilization, not changes in supply. Regardless of any shortcomings in the supply-side data, many scholars have agreed that any shortage is largely a function of changes in utilization, not changes in supply. 18These scholars argue that it is the demand side of the equation that has been drastically altered, principally by the way in which nurses are now used in the health care delivery system. For instance, Prescott, 14 in her discussion of the various models of forecasting health personnel shortages, argues that the substitution of nurses for other workers is largely to blame for the persistent shortage. OthStratton, Dunkin, and Juhl 71

ers concur, stating that the shortage is "self-induced, ''~3 and, at its most basic level, that it is a result of barriers inherent in the health care delivery system itself. 17 Adding to the problem are such factors as retainment difficulties, more acute conditions seen in patients, salary compression, a lack of professional advancement, and increases in nontraditional employment opportunities among nurses.8 However unintentional, the resultant terminology that has come to define the situation gives credence to the simplistic assessment that when the cumulative supply of nurses meets or exceeds the cumulative demand, the shortage will cease to be. While scholars debate the origins or the saliency of the shortage itself, a great many providers in various regions of the country are likely to be faced with the task of conducting "business as usual" under exceedingly anemic staffing conditions. 24 Figures that only 3 years ago placed RN vacancy rates at 12.7% for hospitals and 18.9% in nursing homes attest to the potential gravity of the problem. 2s Furthermore, preliminary figures from the American Hospital Association indicate that vacancy rates have changed very little since 1986, 22 suggesting that reactions to the problem may have changed more than the problem itself.

Any shortage of nurses is as likely a regional maldistribution as of supplyversus-demand economics. Usually thought to be most acute in rural and inner-city settings, any shortage of nurses is as likely a function of regional maldistribution as of supplyversus-demand economics. As a result, the detrimental effects resulting from the inequitable distribution of nurses has not affected all geographic regions 72

Stratton, Dunkin, and Juhl

or institutional settings equally. The effects may vary considerably within underserved areas themselves, with the smallest rural facilities (i.e., hospitals __<25 beds) having the most acute shortages and potentially suffering the brunt of the subsequent effects (e.g., the temporary curtailment of nursingrelated services). 26-zs This article examines the nursing shortage by providing a descriptive analyses of U.S. counties federally designated as nurse-shortage areas. In identifying the geographic regions of the country for which the shortage of nurses is most acute, a basic demographic profile of shortage counties is formulated in hopes of lending some additional insights into the nurseshortage problem within the broader scope of rural practice settings. METHODS

Our analyses are based on county-level data contained in the Area Resource File, a comprehensive database maintained by the Bureau of Health Professions, the Department of Health and Human Services. Shortage designation data for May 1990 was provided by the Office of Shortage Designation, the Bureau of Primary Health Care (BPHC). [The BPHC was previously the Bureau of Health Care Delivery and Assistance; to avoid confusion, BPHC will be used in all future references.] U.S. counties designated by the BPHC as nurse-shortage areas 29, 3owere matched to corresponding Area Resource File county-level records by using state- and county-level Federal Information Processing Standards codes. The final enumeration consisted of 3080 U.S. counties, 2461 designated as nonshortage counties and 619 designated as shortage counties?~' *Although 622 U.S. counties were officially designated as nurse-shortage ar. eas in 1990, county-level data for the state of Alaska is not available in the Area Resource File; as a result,, the Alaskan shortage counties of Ketchikan Gateway, Kodiak Island, and Wrangell-Petersburg are omitted from the analysis, reducing the total analyzable counties to 619.

Because a city or a county as a whole is not a shortage area, larger cities containing numerous nonpublic hospitals tend not to appear on the list, though individual facilities may have shortages. And because the methodology develops requirements for nurses on the basis of hospital patient census numbers, counties that have no hospitals do not show up on the shortage list, even if they contain no nurses. By this methodology,29,30 shortage figures are based on a total of 619 counties located in 45 states, comprising a computed total of 21,699 nurses. FINDINGS

Demographic Distribution of Shortage Counties As is evident in Table 1, the overwhelming majority (92.4%) of shortage areas are situated in nonmetropolitan counties. Not surprisingly, the largest percentages (60.1%) of these areas are located in nonmetro counties not geographically adjacent to a metropolitan area. Furthermore, with regard to population size, the counties classified by the U.S. Department of Agriculture as "less urbanized" (2499-20,000 population) account for t h e majority (55.3%) of nurse-shortage counties. Of the 47 (7.6%) metropolitan counties designated as nurse-shortage areas, only one (0.2%) was situated in a large metropolitan core county.

Geographic Distribution of Shortage Counties In the analyses below, the emphasis is shifted from population distribution to geographic distribution of U.S. counties designated by the BPHC as nurseshortage areas. As Table 2 illustrates, the distribution of U.S. counties designated as nurse-shortage areas is not uniform across all regions of the country, with the West and North Central regions of the nation experiencing the most widespread shortages (24.9% and 23.6%, respectively). Conversely, the Northeast has the smallest percentage (15.7%) of counties designated as nurseshortage areas. Within census regions, specific geo-

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graphic divisions that exhibited the largest proportions of counties designated as shortage areas were situated in the Mountain (30.8%), the West North Central (28.6%), and the East South Central (26.9%) regions of the country.* Figure 1 visually depicts the geographic distribution across the country. Table 3 more clearly outlines the distribution of nurse-shortage designations within nonmetro counties. While Table 1 shows that 572 of the 619 total shortage designations are situated in nonmetro counties, Table 3 suggests that the distribution is not equally distributed across all rural counties. Indeed, in all three nonmetro demographic classifications, a larger percentage of the shortage counties physically occupy geographic locales which are nonadjacent, rather than adjacent, to a metropolitan area. DISCUSSION Traditionally, researchers intent on closely examining the shortage of nurses in rural areas have often focused on job-related factors,31 such as lower salaries and lack of career advancement opportunities. While important, these frequently cited concerns constitute only one dimension of the factors that guide nurses' practice locations. Cordes, 3~ in his broad discussion of economic development and health care, recognized that any truly relevant discussion seeking to link the two must address the structural dynamics of the rural environment as well as the structural factors within the current health care delivery system. On even broader societal levels, others have advocated similar approaches. 33 While progress has been made toward formulating a comprehensive un*The use of "percentage of total counties" is, at best, a preliminary measure of the distribution of the nursing shortage and is used here to identify regional trends. That is, it does not enable variations in magnitude or acuity of nursing shortages to be examined among counties. No direct inference from these aggregate data to individual counties is implied.

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Table 1. Size and Demographic Classification* of U.S. Counties with a Shortage of Nurses, 1990t

Name

Percent of shortage counties within each demographic region~

Description

Metro Counties Large metropolitan core counties Fringe counties

Medium metropolitan

Lesser metropolitan

7.6% (47) Core counties of greater MAs of 1,000,000 or more population Noncore counties of metro areas of 1,000,000 or more population Counties of metro areas of 250,000 to 999,999 population Counties of metro areas of less than 250,000 population

0.2% (1)

1.6% (10)

3.9% (24)

1.9% (I 2)

Nonmetro Counties

92.4% (572)

Urbanized Adjacent§ to MA

5.8% (36) 2.6% (16)

Not adjacent to MA

Less urbanized Adjacent§ to MA

Not adjacent to MA

Thinly populated Adjacent§ to MA

Not adjacent to MA

Total

Counties contiguous to MA that have 20,000 or more urban residents Counties not contiguous to MA that have 20,000 or more urban residents Counties contiguous to MA with <20,000 but >2499 urban residents Counties not contiguous to MA with <20,000 but >2499 residents Counties having <2500 urban residents, contiguous to MA Counties having <2500 urban residents, not contiguous to MA

3.2% (20)

55.3% (342) 22.0% (136)

33.3% (206)

31.3% (194) 7.7% (48)

23.6% (146)

100.0% (619)

MAs, Metropolitan areas. Figures in parentheses represent N. *Rural/urban continuum codes, U.S. Department of Agriculture, 1988 tU.S. counties designated as nurse-shortage counties by the Office of Shortage Designation, Bureau of Primary Health Care, U.S. Department of Health & Human Services, May, 1990 ~Total N = 3080; counties designated as shortage counties = 619 (20.1%) §Counties physically adjacent to one or more MAs and having at least 2% of the employed labor force in the nonmetropolitan county commuting to central metropolitan counties.

Stratton, Dunkin, and Juhl 73

Table 2. Geographic Regions and Divisions* of U.S. Counties with a Shortage of Nursest

Region/division Areas~ Northeast (217) New England

Middle Atlantic

Comprising states

Maine, Vermont, Massachusetts, New Hampshire, Connecticut, Rhode Island (67) New York, New Jersey, Pennsylvania (150)

North Central (1055)

East North Central West North Central

South (1391) South Atlantic

East South Central

West South Central

Pacific

15.7%

(34)

6.0%

(4)

20.0% (30) 23.6% (249)

Ohio, Michigan, indiana, Illinois, Wisconsin (437) Minnesota, Iowa, Missouri, Kansas, Nebraska, South Dakota, North Dakota (618)

16.5% (72) 28.6% (177)

16.7% (232) Delaware, Maryland,

Virginia, District of Columbia, West Virginia, North Carolina, South Carolina, Georgia, Florida (557) Kentucky, Tennessee, Mississippi, Alabama (364) Arkansas, Louisiana, Texas, Oklahoma (470)

West (417)

Mountain

Percent area/regional counties designated as shortage

15.6% (87)

The relationship between rural economic vitality and rural health care delivery has not been well documented.

26.9% (98)

10.0% (47) 24.9% (104)

Montana, Wyoming, Colorado, New Mexico, Arizona, Utah, Idaho, Nevada (279) Washington, Oregon, California, Alaska,§ Hawaii (138)

TOTAL

30.8%

(86)

13.0% (18)

(619)

Figures in parentheses represent N. *Census region codes and names and census division codes and names taken from the Office of Data Analysis and Management's Health Service Area Access System tU.S. counties designated as nurse-shortage counties by the Office of Shortage Designation, Bureau of Primary Health Care, U.S. Department of Health and Human Services, May, 1990. ~Total N = 3080; counties designated as shortage counties = 619 (20.1%) §Although a part of the Pacific region, Alaska shortage counties have been omitted from the analysis due to the unavailability of county-level data.

74

derstanding of how these various economic and health-related issues may affect recruitment and retention, the relationship between rural economic vitality and rural health care delivery has not been well documented, particularly as it pertains to nursing services and personnel. The analysis presented here, while unable to pinpoint specific factors that inhibit nurses from practicing in rural settings, does widen the discussion of a problem that has seen mean RN/population ratios in metropolitan areas widen to nearly twice that of nonmetropolitan counties. 34 A more direct effect of structural factors on rural nursing practice may be seen in rural nursing administrators' difficulties in recruiting and, to a somewhat lesser extent, retaining staff nurses, as Clearly, when combined with substantial discrepancies in salaries and benefits, 34, 36 these difficulties are only exacerbated by the presence of complex environmental factors, 37

Stratton, Dunkin, and Juhl

Admittedly, the primary impact of local economies on the provision of nursing care is manifested in the recruitment and retention of health professionals (including nurses)-an undertaking that, if unsuccessful, further erodes the local health care infrastructure needed to attract new businesses and stimulate growth. 3z At its most basic level, then, the relationship between physical health and economic health is both reciprocal and interdependent. More important, economic instability greatly impedes the ability of smaller communities to successfully compete for nurses in what has become a highly competitive marketplace.

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To better illustrate, many rural areas cannot accommodate dual-income families, par tieularly when a nurse's spouse is also a professional. Furthermore, in an effort to offset rising costs and declining patient volume, rural hospitals are forced to offer comparatively lower salaries, 34 making survival even more challenging for single-parent or single-income households. Not immune to these economic concerns, many highly skilled nurses have been forced to abandon their practices and join the rural exodus.38

Many rural areas cannot accommodate dual-income families.

Figure 1. Nurse shortage areas in 1990: designated counties.

Table 3. Distribution of Nurse-Shortage Areas Within Nonrnetropolitan* Counties of the U.S.t Classification

SUMMARY A number of researchers have suggested that nursing shortages are closely related to geographic maldistribution, 39 specialty areas, and even individual shifts. 4° As these findings have documented, the nursing shortage, as defined by the federal government, exists predominantly in rural areas of the country that are not adjacent to metropolitan areas. As a result, many of the economic, demographic, and healthrelated disparities that exist between rural and urban populations are mirrored in shortage and nonshortage counties.* Higher unemployment rates and lower per capita incomes suggest an underlying relationship between economic vitality and the recruitment and retention of health care personnel. This suggests that a fundamental obstacle to staffing adequate numbers of qualified nurses in rural areas may not be a *For a more comprehensive comparison and discussion of rural versus urban health care, see Norton CH, McManus MA, Background tables on demographic characteristics, health status, and health services utilization. Health Serv Res 1989;23:725-56 NURSING OUTLOOK

Urbanized Adjacent~ to MA Not Adjacent to MA Less Urbanized Adjacent~ to MA Not adjacent to MA Thinly Populated Adjacent~ to MA Not Adjacent to MA Total

Shortage

Nonshortage

Total

(16) 11.7% (20) 13.3%

(121) 88.3% (130) 86.7%

(137) 5.8% (150) 6.4%

(136) 24.7% (206) 27.5%

(415) 75.3% (543) 72.5%

23.3% (749) 31.7%

(48) 21.1% (146) 26.7%

(180) 78.9% (400) 73.3%

(551)

(228) 9.7% (546) 23.1% (2361) 100%

MA, Metropolitan area. Figures in parentheses represent N. *Rural/urban continuum codes, U.S. Department of Agriculture, 1988 tU.S. counties designated as nurse-shortage counties by the Office of Shortage Designation, Bureau of Primary Health Care, U.S. Department of Health and Human Services, May, 1990 ~Counties physically adjacent to one or more MAs and having at least 2% of the employed labor force in the nonmetropolitan county commuting to central metropolitan counties

shortage of nurses, but economic barri- medically underserved settings. Howers (domestic and health care related) ever, while the notion of producing deeply rooted in the rural settings appropriate "types" of nurses is well themselves. 41 founded, the temptation to "solve" the In those states burdened with signif- problem simply by producing more icant shortage areas, emphasis must be providers should be resisted, since it placed on easing the maldistribution of will not markedly benefit those areas available nurses away from rural, often that are currently in greatest need. The

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Stratton, Dunkin, and Juhl 75

t i m e frame necessary for s u c h " t r i c k l e d o w n " approaches to affect rural areas could, w h e n c o m b i n e d w i t h o t h e r factors, r e n d e r m a n y h e a l t h care d e l i v e r y systems v i r t u a l l y unsalvageable. T o address t h e persistent distribution p r o b l e m , w e could c h a n g e h o w h e a l t h professionals are educated. M a n y n u r s i n g a d m i n i s t r a t o r s in rural areas have, for years, recognized w h a t e m p i r i c a l research has o n l y r e c e n t l y documented --that employees who m a i n t a i n strong ties to an area are, c o m p a r e d w i t h those w h o s i m p l y locate t h e r e for t h e job itself, far m o r e l i k e l y to stay. As a result, some of t h e m o r e effective staffing strategies have developed and r e t a i n e d local talent, r a t h e r t h a n e n t e r i n g t h e costly and c o m p e t i t i v e arena of e x t e r n a l recruitment. I m p l e m e n t e d on a broader scale, these insights h o l d great p r o m i s e for i n d i v i d u a l states c o n t e m p l a t i n g legislative efforts to assist rural areas in t h e r e c r u i t m e n t and r e t e n t i o n of n u r s i n g personnel. 42

Some of the more effective staffing strategies have developed and retained local talent. A l t h o u g h some have c o n t e n d e d that t h e t u r n o v e r of h e a l t h personnel in rural areas is u n a v o i d a b l e and t h a t t h e focus s h o u l d be on t h e c o n t i n u i t y of services, r a t h e r t h a n on t h e c o n t i n u i t y of the i n d i v i d u a l practitioner, 43 this assessment s h o u l d not be m e a n t to imp l y t h a t a n y factor constitutes an ins u r m o u n t a b l e barrier to successfully staffing adequate n u m b e r s of n u r s i n g personnel. In m a n y instances, creative and w e l l - i m p l e m e n t e d r e c r u i t m e n t and r e t e n t i o n programs can conceiva b l y o v e r c o m e e v e n the most seemi n g l y i n s u r m o u n t a b l e barriers faced b y rural providers. 36, 44 W e s h o u l d h e l p those states t h a t 76

Stratton, Dunkin, and Juhl

c o n t a i n significant nurse shortage counties to address t h e p r o b l e m by form u l a t i n g strategies t h a t e x t e n d b e y o n d m e r e l y nurses and nursing. Policies a i m e d at easing the shortage of n u r s i n g personnel in rural areas m u s t recognize the s t r u c t u r a l barriers t h a t i n h i b i t rural settings f r o m attracting and retaining t h e i r fair share of available nurses. Equally serious a t t e n t i o n m u s t be paid to related rural issues, such as econ o m i c d e v e l o p m e n t , t h e shortage of o t h e r h e a l t h care providers, hospital v i a b i l i t y , M e d i c a r e / M e d i c a i d reimb u r s e m e n t s , and v u l n e r a b l e populations. O n l y w h e n these related factors are realized and addressed in rural areas w i l l it t r u l y be possible to speak of t h e n u r s i n g shortage in t h e past tense. • Supported, in part, by funding from the Office of Rural Health Policy, U.S. Department of Health and Human Services (Grant No. CSR000005"0 I-0). We gratefully acknowledge the assistance provided by the Office of Analysis and Research and the Officeof Shortage Designation, Bureau of Primary Health Care, U.S. Department of Health and Human Services. We would also like to thank the North Carolina Rural Health Research Program at the Cecil G. 8heps Center for Health Services Research, Chapel Hill, N.C., for their assistance with graphics.

REFERENCES

1. Erwin W. AHA survey, nurse shortage eases dramatically. Hospitals 1993;67(3),52. 2. Brider P. Annual nursing salary survey~ Where did the )obs go? Am J Nuts 1993; 93(4):31-6, 38-40. 3. MosesEB. Registered nurse shortage seen for the 21st century: as I see it. Am Nurse 1992;24(7),4. 4. Ambrose Y. Nursing in 2001~Are you ready? Nurs Manage 1990;21(12),45,48. 5. American Nurses Association. RN population seen declining after the year 2000~ HHS predicts shortage could top 800,000 by 2020. Am J Nurs 1990;90(9)~97,110. 6. Chambers JD. Predicting licensed nurse turnover in skilled long-term care~organizational characteristics, climate, and group characteristics. Nurs Health Care 1990;11,474-8. 7. Dunkin JW, Kindig DA, Ludtke RL, Movassaghi H. Trends in hospital-based nurses in rural areas, 1981-1986. Grand Forks, North Dako[m UND Rural Health Research Center, 1990. 8. LeppaC. Nursing supply and demand. Midwest Alliance in Nursing (MAIN) Fact Sheet 1985;1(1)..1-4. 9. Smith DL, Molzahn-Scott AE. A comparison

of nursing care requirements of patients in long-term geriatric and acute care nursing units. J Adv Nuts 1986;I1(3)d5-21. 10. Abdellah FG. The nursing shortage, dynamics and solutions. Reflections on a recurring theme. Nurs Clin North Am 1990;25~50916. 11. Rodgers BL. Concepts, analysis and the development of nursing knowledge, the evolutionary cycle. JAdv Nurs 1989;14(4)~330-5. 12. Prescott PA. Shortage of professional nursing practice, a refraining of the shortage problem. Heart Lung 1989;1&436-43. 13. Prescott PA. Another round of nurse shortage. Image J Nurs Sch 1987;19,204-9. 14. Prescott PA. Forecasting requirements for health care personnel. Nurs Econ 1991;9,1824. 15. Brush BL. Shortage and shorthand, for the crisis in caring. Nurs Health Care 1992; 13:480-6. 16. Moccia P. The nursing shortage, dynamics and solutions. Toward the future= How could 2 million registered nurses not be enough? Nuts Clin North Am 1990;25,60513. 17. Hall JM, Stevens PE. The nursing shortage in the context of national health care. NuRs OUTLOOK 1991~39,69-72. 18. Prescott PA, Phillips CY, Ryan JW, Thompson KW. Changing how nurses spend their time. Image J Nurs Sch 1991;23,23-8. 19. DHHS Secretary's Commission on Nursing. Final Report. Vol. I. Washingtom US Government Printing Office, 1988. 20. Aiken LH. Nursing's future: public policies, private action. Am J Nurs 1983; 83(10):1440-4. 21. Ritter JK. How many nurses are there? Will you please count off from left to right, starting in Alaska! 1 . . . 2 . . . 3 . . . . Issues 1991;12(1),4,11. 22. Burda D. Nursing shortage! Nursing shortage? It seems to depend on who's talking. Mod Healthc 1992; (April 20),34-5. 23. Lindemann AR, Haugen D. Modern medicine=what you're dying to know, a consumer action guide. Fargo, North Dakota, Personal Best Press, 1992d41-65. 24. Fraser CG Jr. The demand for nurses outstrips available supply. The Medical Herald 1991;1(2),4. 25. American Nurses Association. The nursing shortage. Am Nurse 1991;23,6. 26. Stratton TD, Briggs Lausch C. Registered nurse employed in rural hospitals and skilled-nursing facilities (SNFs), descriptive findings from a multi-state study. Grand Forks, North Dakota, UND Rural Health Research Center, 1992. 27. Lawler TG. The nursing shortage and its implications for rural health. Tar Heel Nurse 1988;50(3),8-9. 28. Styles MM. The nursing shortage, real problems, real solutions. Keynote address presented at the Dakota Conference on Rural Health. Bismarck, North Dakota, March 1-3, 1988. 29. Bureau of Primary Health Care, Office of

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30.

31. 32.

33.

34.

35.

Shortage Designation, U.S. Department of Health & Human Services. Methodology used to develop nurse shortage area list; characteristics of list. Unpublished correspondence, May, 1990. Lee RC. Current approaches to shortage area designation. J Rural Health 1991;7(Suppl)= 437-50. Donovan L. What nurses want (and what they're getting). RN 1980;43(4):23-30. Cordes SM. The changing rural environment and the relationship between health services and rural development. Health Serv Res 1989;23:757-84. Field MG. The concept of the "health system" at the macrosociological level. Soc Sci Med 1973;7:763-85. Movassaghi H, Kindig DA, Juhl N, Geller JM. Nursing supply and characteristics in the nonmetropolitan areas of the United States, findings from the 1988 National Sample Survey of registered nurses. J Rural Health 1992;8,276-82. Stratton TD, Dunkin JW, Juhl N, Ludtke RL, Geller JM. Recruiting and retaining registered nurses in rural community hospitals; some administrative assessments. J Nurs Adm 1991;21(11),30-4.

36. Parker M, Polich CL, Olson D, Hay M. A rural hospital responds to the nursing shortage. Nurs Econ 1989;7,215-17. 37. Henry BM, Moody LE. Nursing administration in small rural hospitals. J Nurs Adm 1986; 16(7-8):37-44. 38. Fuszard B, Slocum LI, Wiggers DE. Rural nurses, II= surviving the shortage. J Nurs Adm 1990;20(5):41-6. 39. Sloan FA, Richupan S. Short-run supply responses of professional nurses: a microanalysis. J Human Resources 1975;10~241-7. 40. Hixson JS. The recurrent shortage of registered nurses: a new look at the issues (publication No. HRA-81-23). Washington: US Government Printing Office, 1981. 41. Stratton TD, Dunkin JW, Juhl N, Geller JM. Recruiting registered nurses to rural practice settings: an assessment of strategies and barriers. Appl Nurs Res 1993;6(2),64-70. 42. Stratton TD, Gibbens B, Dunkin JW, Juhl N. How states respond to the rural nursing shortage. Nurs Health Care 1993;14:238-43. 43. Fulton GP, Syiek JA, Evans CW, Mayes CR. Strategies for a statewide improving ge°graphic distribution of health professionals. J Med Educ 1980;55:865-71. 44. Sowell R, Bramlett MH. A collaborative ap-

proach to the nursing shortage in rural areas. NursingConnections 1988;1(2),51-61.

TERRY D. STRATTON, previously a research analyst at the Rural Health Research Center, School of Medicine, University of North Dakota, is a doctoral student in Sociology and a research assistant in the Department of Behavioral Science at the School of Medicine, University of Kentucky, Lexington.

JERI W. DUNKIN is director of the Rural Nursing Research Division, Rural Health Research Center, School of Medicine, at the University of North Dakota. She is also an associate professor and director of the Rural Health Nursing Specialty at the University of North Dakota, in Grand Forks. NYLA JUHL is an associate professor and director of the Parent-Child Nursing Specialization, College of Nursing, University of North Dakota, Grand Forks.

BARRY UNIVERSITY SCHOOL OF NURSING PRIMARY CARE NURSING CENTER INVITES APPLICATIONS AND NOMINATIONS FOR ADMINISTRATIVE DIRECTOR, PRIMARY CARE NURSING CENTER The Primary Care Nursing Center of Barry University is a highly dynamic, creative center dedicated to an innovative delivery of primary care nursing to children, families, teachers and members of the surrounding communities of 4 elementary schools. Each school is a self contained mini-center of the larger center. The Primary Care Nursing Center is a center without walls in 5 locations. Delivery of health care to the economically disadvantaged children of the school has reached over 1,500 children as well as their families and communities. The center is fully operational and successful and is the receipt of many grants. The experience and personal attributes desired of the Administrative Director should be: • Energentic, enthusiastic and flexible in the provision of leadership to the center and school. • A visionary of primary care nursing in the school and community. • Highly experienced in the delivery and case management of primary care nursing as a nurse practitioner. • MSN or higher degree as School Nurse Practitioner or Pediatric Nurse Practitioner from an acredited college or university. • Knowledgeable in fiscal management. • Sensitive to diverse educational, cultural, social, and ethnic characteristics. This stimulating opportunity will be compensated according to education and experience. Send nominations or application to: Patricia Munhall, ARNP; Ed.D; Psy.A., FAAN Associate Dean, Graduate Program in Nursing and Director, Primary Care Nursing Center Barry University School of Nursing 11300 NE. Second Avenue Miami Shores, Florida 33161 An equal opportunity employer

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