Alyson Rodriguez MDE Student at Bassett Medical Center

Country Roads

Bassett Practice Integration Program Prepares Students to Treat Rural Populations

There was something about the head-to-toe physical,” muses Columbia Nursing DNP student Michelle Stevenson, MS ’20, who recently completed a two-week rotation at Bassett Healthcare Network, based in rural Cooperstown, New York. The experience at Bassett confirmed many of Stevenson’s assumptions about what nurse practitioners (NPs) can do and gave her a new appreciation for the whole-person care delivered by health care providers in rural areas.

“My preceptor was the provider whom commercially licensed truck drivers saw for their required physicals,” Stevenson explains, “which were more robust than I expected. Besides performing all the routine checks that you learn as an NP, she spent extra time examining drivers’ peripheral vision and neck muscle strength. She needed to make sure that they had enough range of motion to see their sideview mirrors.”

And, Stevenson adds, “if a driver had sleep apnea, she asked if they were using their CPAP machine,” a breathing device that’s a common treatment for sleep apnea, “because a sleepy driver becomes an unsafe driver. She said her job was to keep the roads safe. That is something I never thought about.”

Nursing students walking outside Emergency Room

Until her rotation at Bassett—some of whose funding comes through a federal program that provides primary care services in underserved areas—Stevenson had acquired most of her clinical experience in New York City’s highly urban South Bronx neighborhood. She was eager to work in an underserved setting whose challenges differed substantially from those she’d dealt with in an inner city. “I wanted to see what it would be like to practice in a rural setting, one less fortunate in terms of resources, where practitioners would need to be more hands-on than those who have more resources,” Stevenson explains. The Bassett clinical rotation gave her this opportunity.

Columbia launched the program in 2017 to expand its students’ perspectives on health care delivery and resources, patient-provider relationships, and what it means to be well served, explains Judy Honig, DNP ’05, EdD ’95, vice dean of academics and dean of students at Columbia Nursing. The rotation, which is open to students in the Masters Direct Entry (MDE) program and the Family Nurse Practitioner (FNP) program, exposes students to situations, such as the inability to access specialty care, that they do not typically encounter in the school’s urban setting. “We try to give our students a wide breadth of clinical experience to broadly prepare them for their career,” Honig says. “Being an urban institution, we don’t have a rural perspective on health care, where resources are sparser and more spread out, patients do not have easily accessible specialty services, and primary care takes on a larger role. In a rural environment, referrals are different, patients are different, and ways of life are different. It’s a whole other dimension.”

Integration is Essential to Nursing Preparation

Heidi Hahn-Schroeder, DNP, RN, Assistant Dean, Academic Affairs

Practice integration, a required aspect of Columbia’s curriculum, allows students to incorporate everything they’ve learned academically and clinically, explains Heidi Hahn-Schroeder, DNP, an assistant dean, an assistant professor of nursing, and the director of the MDE program. “Integration is the capstone of the prelicensure education that is most representative of a nurse’s full-time, working experience,” Hahn-Schroeder says. “The Bassett integration program is unique because it provides an  opportunity for students to compare and contrast their previous clinical experiences in an urban health care system with those of a rural health care system.”

For Cally Cochran, MS ’21, an Arkansas native who plans to practice in the rural South or Midwest, Bassett provided the intimate experience of a smalltown hospital that she had missed. “The nurses, technicians, doctors, physician assistants, and NPs in the emergency department were all eager to include me in everything that happened,” Cochran says. “I got to see the full spectrum of care, from triaging patients, to performing CPR in a successful code, to watching an emergency heart catheterization. The best part was the sense of teamwork and family between the various members of the health care team and also with the patients and their visitors.”

As with all of Columbia’s integration programs, whether they’re in the heart of New York City or in far-flung international or U.S. locations, students must apply and be accepted for the Bassett rotation. The program in Cooperstown—the headquarters for the Bassett Healthcare Network, which includes the 180-bed Bassett Medical Center, four smaller community hospitals, a number of outpatient clinics, a nursing home, and several other health care facilities—requires students to live in the community for their entire rotation. “Health care starts in the community, and so we immerse the students in Cooperstown for the six weeks that they’re there,” Hahn-Schroeder says.

The Challenges of Rural Health Care

At Bassett, as at other rural health care facilities, challenges abound, explains Tommy Ibrahim, MD, MHA, the president and CEO of the Bassett Network. “Rural health care has challenges in geography, social determinants of health, and socioeconomic considerations,” among other factors, he points out.

One major challenge is access. “Accessing care is much more difficult in a rural setting,” Hahn-Schroeder notes. “In the city, patients can choose from numerous hospitals, but for most people in Cooperstown, Bassett is the only accessible hospital.” This can make getting routine primary care particularly difficult. “People sometimes have to travel much further to get the most basic care, which may impede their ability to manage their chronic illnesses,” she explains.

“When you’re dealing with underserved populations, social determinants of health may limit their ability to maintain their health,” says Ellen Fahey, DNP, an assistant professor of nursing, the director of Columbia’s FNP program, and the liaison between FNP students and Bassett. “Working in a rural setting, where resources may not be as accessible as they are in an urban setting, demands a focus of care that is complex and comprehensive.”

Limited resources may also mean nursing students need to learn more skills, and take more initiative. DNP student Michelle Marchiano, MS ’21, completed her integration as an MDE student at Bassett’s 25-bed Cobleskill Regional Hospital, which has one respiratory therapist, two doctors, and four telemetry monitors—portable devices that monitor patients’ ECG, respiratory rate, and/or oxygen saturation while automatically transmitting the information to a central monitor. “At New York-Presbyterian, you have multiple respiratory therapists working in tandem with doctors, an entire floor dedicated to telemetry, and nurses who are specially trained in it,” Marchiano says. “Normally, doctors give nurses specific orders regarding telemetry, but at Cobleskill they gave the nurses a lot of latitude in terms of changing oxygen settings and monitoring telemetry. Instead of specializing in telemetry, nurses have to know a little bit of everything.”

Broadening Perspectives and Practice

Student and Preceptor using medical training device at Bassett

Because care at Bassett is not as compartmentalized as it is in urban areas, students get a much broader scope of experience, Dr. Ibrahim points out. “Due to the unique needs of our patients and the difference in available specialties, nurses experience and provide a much wider variety of care than they would in NYC. Our nurses are expected to have a very broad scope of knowledge and skills that they apply every day,” he adds.

That is exactly what Marchiano wanted. “In an urban setting,” she says, “nurses often don’t go to their full scope of practice because we have specialty individuals who can step in and take some of that load. In a rural setting, where you are juggling so many patients, you are multitasking, prioritizing who’s most important and what needs to be done first. You are working at your full scope of practice.” This boosted her appreciation for hospitals where resources are plentiful. “Once you work in a rural setting, you don’t take for granted what you have in a high-resource situation.”

Rural Settings Promote Close Patient-Provider Bonds

Another plus of the Bassett program for students is they learn that small-town patient-provider relationships run deep. That’s not only because nurses provide the bulk of primary and specialty care, but also because they often live in the same community as their patients, Marchiano points out. “In small towns, where everybody knows everybody else, nurses know patients on a personal level, as neighbors,” she says.

Even the limited health care resources in the Cooperstown region help to strengthen patient-provider relationships, Stevenson notes. “When you don’t have access to specialists and a greater health care network, then you have to spend a little more time engaging with patients and are more likely to see them on a regular basis and even care for their entire family,” she says. For example, a city-based primary care practice will typically refer women to an obstetrician-gynecologist or an NP who specializes in women’s health. But “in a setting where these specialty services are less available,” she adds, “NPs perform the kind of procedures—like a Pap smear—that we wouldn’t ordinarily do because we can more readily refer to specialty care.”

Two nurses preparing to see their next patient

Stevenson describes another case in point—a mentally ill young woman who was having an especially difficult time coping with the death of a loved one. The woman’s NP performed a routine psychosocial screening and medication management. Then, since she was a certified hypnotherapist, she also conducted a hypnotherapy session for the patient. “This was not something we would see in a primary care office in the city, where we would refer out to a complementary medicine specialist,” Stevenson says. “The NP clearly had established a bond with her patient, who trusted her enough to go through the session—even with me, a nursing student, standing there,” she adds. The patient was very grateful and returned for another appointment a couple of weeks later. “Her NP checks in on her regularly to make sure she’s okay,” Stevenson points out. “They have an established and ongoing relationship.”

Thanks to such relationships, NPs in rural settings are able to provide holistic care, addressing patients’ mental health needs and ensuring that they have the resources and ability to fill prescriptions and follow up on treatment instructions. “People know each other, and providers know their patients in depth,” Stevenson says. “Their relationships go back many years. That type of connection affects the quality of care a patient receives.”

Like many of the students who choose the Bassett clinical rotation, Stevenson hopes to practice primary care in an underserved setting. Spending two weeks at Bassett prepared her well, she feels. “You learn to see a patient as a whole person within the context of their family and home setting,” she says, and “recognize what they’re capable of doing medically, based on resources that they can or cannot access, and know where they are in their life picture.”

Hahn-Schroeder agrees, pointing out that “the more understanding we have of people from diverse populations and communities, the better we are able to care for them. It only enriches our practice.”

This article originally appeared in the Spring 2022 issue of Columbia Nursing Magazine.