|Author: Julia Elliott|
|Total Care for the Rural Patient|
|In a "cradle to grave" practice that she built one patient at a time, family nurse practitioner Nancy H. Noble, RN, MS, ARNP-C, cares for a rural population. She credits her experiences working at Community Rural Health Clinics of Holton, KS, with keeping her skills sharp.
A book she read as a girl around 1960 sealed Noble's career choice at an early age. "I read a book that was part of a series about Sue Barton, RN, when I was 10 years old," she recalls. "I think the fact that this nurse was having fun while helping people was what appealed to me," recalls Noble.
Because she lived in the country -- 10 miles from the nearest town -- Noble missed out on some of the hands-on learning that many future nurses get to experience in more populous areas. Ther e was no candy striper program available to her during her teens, for instance. "When I finished nursing school and began my first day as a nurse, I was so green," she admits. Soon, however, a unique opportunity materialized for her.
"I got married 196 7 and when my husband was transferred to Alaska, I joined him shortly after graduation," Noble explains. During the six months she spent practicing in Alaska, Noble shed her youthful inexperience working in a 30-bed, Native Alaskan hospital in the isolate d town of Tanana, located near the junction of the Yukon and Tanana Rivers. The town and the hospital were accessible only by boat or by air. "Pregnant women would be transported to our facility two weeks ahead of their due date and actually live there until the baby was born," Noble recalls. "When children became sick, they would be brought by airplane, usually [with] someone other than their mother, because she had to stay back home in the cabin with eight or 10 other children. When the child got well, we put them into the arms of someone that would be going to that village, and they would deliver them back into the family fold."
Those six months in Alaska afforded Noble a glimpse into a world where a healthcare facility had a relationship with the su rrounding community that she had never before seen. It was also during this time that she first heard about nurse practitioners. The young RN soon began to research the broad scope of practice that this new profession offered. Noble continued her career a s an RN, taking courses at the local university towards her bachelor's degree while raising her children. She moved to Ohio long enough to complete her bachelor's degree at Kent State University, and then moved back to Kansas to pursue her master's degree.
"I had followed this profession since I first heard about it in the 1970s," says Noble. "I was fascinated, and watched it develop over the years, and I realized that this was the role I would really like." Noble again found herself at work in a remote setting when she was inadvertently recruited to be director of nursing (DON) at a rural hospital in Onaga, 38 miles from her home. During her tenure as the DON at the hospital in Onaga, Noble was pursuing her MS while increasing her clinical expertise.
In 1989, Noble finished her MS, trained as a clinical nurse specialist in cardiology and medical-surgical nursing. She was eager to apply her advanced training when she got some exciting news. "When I learned the University of Kansas [located in Lawrence, KS] was opening a new program to educate nurse practitioners, I called them and told them I wanted in."
Although the university told her there was no room, she told them that she intended to come anyway. "I had waited many years for this program, but with small children, there was never enough time to travel to the far-off places [The university was three hours away in Lawrence, KS.] that offered this program. I never lost the dream to become a nurse practitioner, but put it on the back burner while I raised my children." Now that there was a program available within a reasonable distance and Noble's children were grown, there was no stopping her. Fortunately, a spot opened up and she was accepted. Her determination never waned as she regularly commute d 100 miles to the University of Kansas Medical Center along with several other nurses living in rural areas, finishing the program in 1994.
Just before she completed her NP studies, Noble agreed to cover a clinic in Centralia, another small rural community. Onaga Hospital had rural health clinics in four remote surrounding towns: Centralia was one of these. "I had planned to continue working in the hospital setting at Onaga, but the need was at Centralia, a town with a population of 300," she recalls.
At first, Noble was terrified at the thought of working in a clinic whose hospital support was 20 miles away. She now says that the clinic in Centralia was where she learned what it meant to be a nurse practitioner, to develop long-term relationships and to become a part of a community. Although she was the only healthcare provider in Centralia and her commute to the clinic was 53 miles from home, Noble did not mind at the time because it was supposed to be a short-term arrangement.
However, the short term stretched into seven years. When an opportunity arose for Noble to transfer to a clinic in Holton, 12 miles from her home, she took it. Although the decision to transfer was difficult, it made sense for her to work closer to home in order to help car e for her mother, who at the time, was very ill with Alzheimer's disease.
It was with great anguish that Noble left the clinic in Centralia for Holton, a town with a population of 1,500 to 2,000 people. "I had a great working relationship with my staff a nd my patients, and it was truly where my heart was," Noble recalls. "I changed to Holton in July of 2001, and the first couple of months I wasn't very busy, and I had wondered if I had made a mistake to make this move. Now, two-and-a-half years later, my practice has grown and I am at a point where I am comfortable with the caseload. I am also proud to be the only mid-level practitioner in a town that also has a physician-based practice -- offering interesting competition at times."
Noble works four 10-hour days per week at the clinic, where she sees an average of 20 to 25 patients a day. They present with a lot of chronic conditions, including hypertension, hyperlipidemia, diabetes, asthma, COPD, CHF, urological and neurological problems. Noble provide s treatment with the help of a physician who is on site with her for 12 hours each week. "We work independently, side by side," says Noble. "We believe it is the primary care provider's responsibility to coordinate the total care of the patient."
For th e remaining 28 hours each week, Noble's sponsoring physician is 30 miles away from the clinic. When faced with a challenging case, she gets on the phone to consult or refers the patient to a hospital for medical evaluation. "We see patients with scheduled appointments and deal with walk-in emergencies, do X-rays and need to be proficient in basic X-ray interpretation," says Noble. "I deal with a lot of women's health issues and spend a lot of time with screening and prevention issues, recognizing that the se women are often the gatekeepers of health for the family." Noble realizes that in the rural areas, the best advertising is word of mouth: "If the mother is happy with her healthcare, she will encourage other family members to seek appropriate healthcar e, proving our philosophy that if we take care of one patient at a time to the best of our ability, the practice will grow."
Community Rural Health Clinics of Holton, which also employs a full-time LPN, a medical assistant, a receptionist and a billing p erson, sees a diverse patient population. The variety of patients and conditions keeps Noble sharp and ready for anything. She outlines a typical day's work: "remove the head of a tick that became embedded in the patient's skin; assess and advise a morbid ly obese woman who wanted to transfer from her current physician who wasn't 'listening' to her anymore; examine, treat and evaluate a patient with thrush and a suspicion of having HIV. Another woman came in requesting medication for a seizure disorder, an d another person came in with congestive heart failure, another with back pain, two in the throes of a mental breakdown and the list goes on."
Whether she is treating a misdiagnosed case of chicken pox, an abscessed tooth, a Parkinson's disease patient o r a child that has fallen off the monkey bars, Noble approaches patient with genuine interest and compassion. The patients that come to her clinic present Noble with challenges she is eager to face, providing new learning opportunities every day. "I use the computer a lot and have a whole office full of research/reference books that help me, but I get most of my learning from treating the people that come to me each day.
"The scariest experience I have had was when the director of nursing at the nursing home adjacent to the clinic developed a severe respiratory stridor," remembers Noble. Swelling of the larynx that can block the airway accompanies stridor. If the swelling becomes severe enough, only a tracheotomy can save the patient. Although Noble did not have to perform a trach, she packed her scalpel and prepared herself in case she did. "We put her on the ambulance and notified the receiving hospital and explained that this woman might need a trach done, so they loaded an anesthesiologist on the amb ulance that was heading towards us and we met halfway, where that team took over. This woman had a few more of these unexplained episodes, but today she is back to work and doing fine," Noble says.
She is proud to have worked to attain the career she wan ted as a girl: to be a nurse who loved what she was doing and was having fun doing it, just like the fictional Sue Barton.
Noble credits her children with helping make it happen. "I was a single mother at this time, and my children were teenagers when I was going to school to achieve my dream. They were very supportive," she recalls. "This kept me going in times that I would have not been able to if it were not for them. My son took over and drove his sister to games and appointments in my absence, tak ing up the slack while I continued my studies."
In the future, Noble plans to advise any nurse practitioner students that she mentors not to "bluff your way through this," but to "define the resources, because that is where the answers are. I am flat ope n and honest with people and I urge everyone else to do the same. We do not have all the answers, but it is our job to find the answers."
Nancy H. Noble RN, MS, ARNP-C, of Community Rural Health Clinics, Holton, KS, obtained her diploma from Stormont-Vai l School of Nursing in 1967, her Bachelor of Science from Kent State University in 1981 and her Master of Science from the University of Kansas in 1989. She went on to receive her ANCC certification in primary care in 1994 and obtained her nurse practitioner's credentials from the University of Kansas in 1994.
Julia Elliott is a freelance writer from New York. She is on the editorial staff of NEWS-Line for Nurse Practitioners.