NURS 765 Week 3 Internal or External Frame Factor Assessment Example

External Frame Factors for a Post-Master's DNP in Rural Health Systems Leadership: Community, Health Needs, Workforce, Regulation and Funding in Southwest Virginia

Purpose and Approach

Our task force, now planning a rural leadership practice doctorate, has a basic question to answer before writing outcomes: does the region need the program, and will conditions outside the university allow it to succeed? Keating (2015) separates the frame factors that shape a curriculum into external factors, located in the community, the health care system and the profession, and internal factors, located in the parent institution. This assessment addresses the external factors, because the program's case rests on the needs of a rural region rather than on any gap in the university's existing offerings.

The assessment drew on four kinds of evidence over six weeks: published research on rural health and the nursing workforce, regional health and hospital data, interviews with nine leaders at partner organizations and a short questionnaire answered by nurses with graduate degrees who work across the service area. The sections below follow Keating's external factors in order and end each finding with its meaning for the curriculum.

The Community and Its Population

The program's service area is a set of mountainous, largely rural counties in southwest Virginia and the neighboring parts of Appalachia, where distances are long, broadband is uneven and many residents are older than the state average. Coal and manufacturing jobs have declined, and many families depend on public insurance. Partner leaders described communities with deep loyalty to local institutions and a corresponding sense of loss when a clinic or hospital unit closes.

For the curriculum, these findings point to two decisions. First, the program must be delivered mostly online with a small number of intensives, since asking working nurses to travel weekly over mountain roads would exclude the very students the program exists to serve. Second, community engagement cannot be a single course topic; graduates will lead in places where trust in institutions has been strained, so community partnership belongs in the outcomes.

The Health Care System and the Health Needs of the Population

The health care system in the region rests on a small number of critical access and community hospitals, federally qualified health centers, rural health clinics and local health departments. Its fragility is the central external fact for the program. Liu et al. (2026) followed 33,716 Medicare beneficiaries with cancer and found that patients with colorectal cancer living in rural counties where a hospital closed had significantly higher all-cause mortality than before the closure, with no such change in matched rural counties that kept their hospitals. Closures, in other words, are not only an access inconvenience; they can be measured in survival.

Screening shows a related pattern. Namin et al. (2026) mapped geographic access to colonoscopy across all census tracts in the contiguous United States and reported that colorectal cancer incidence and mortality are disproportionately high in rural and Appalachian communities, where screening is more often delivered by general surgeons than by gastroenterologists. Partner leaders confirmed that preventive services, chronic disease management and behavioral health, including substance use treatment, are the needs they most often cannot meet.

For the curriculum, the health needs finding means that population health, chronic disease and access to care must anchor at least one core course, and that DNP projects should be encouraged to address problems partners can name, such as screening rates, readmissions or care transitions after a unit closes.

The Political and Regulatory Climate

Two regulatory conditions shape what graduates can do. The first is state scope of practice for nurse practitioners, since many applicants will be practitioners. Miller and Barut (2026) studied nurse practitioners in Tennessee, a neighboring state that still restricts practice, and described how regulatory barriers in states without full practice authority limit the capacity of advanced practice nurses to provide care. Our graduates will practice on both sides of state lines in this border region, so the curriculum must teach the policy process and the evidence on scope of practice rather than one state's rules.

The second is federal regulation of critical access hospitals. Metzger (2026) argues that the Medicare conditions of participation still require physician-led medical oversight in these hospitals despite three decades of growth in the number, education and rural distribution of nurse practitioners, and that the rules exclude nurse practitioners from medical leadership roles without demonstrated gains in quality. Several partner hospitals in our area are critical access hospitals, and their nurse leaders work inside these rules daily. The curriculum's health policy course should therefore include a project in which students analyze a current federal or state rule that affects rural care and draft a policy brief, which serves both the AACN Essentials domain on policy and the region's real needs.

The Nursing Profession and Employers

Most graduates will return to the organizations that employ them now, so employers' expectations are a frame factor in their own right. Beeber et al. (2019) found that employers in nonacademic settings understood the DNP-prepared nurse's role unevenly, and our interviews matched that finding. Of the nine partner leaders, most could describe what they wanted, such as leaders who could run improvement projects, use data and manage teams across sites, but few connected those abilities to the DNP degree itself. Smith and Laver (2026) describe nurses as standing at the front of rural health services disruption, from workforce shortages to closures, and argue that the profession's position in rural systems gives it both responsibility and influence in how those systems respond.

The curriculum response is to make the DNP project a partnership with the student's employer from the first semester, so that the degree's value is visible to the people who will promote its graduates. Employer letters of support will be part of admission, as the workshop paper proposed.

Other Programs in the Region

The assessment found several online DNP programs that enroll nurses from the region, most with executive leadership or advanced practice tracks designed for urban health systems. None of the programs reviewed was built around rural systems, and few required in-person intensives or regional project partners. The one published model that fits this gap comes from the Pacific Northwest, where Martinez et al. (2026) built regional cohorts of rural nurse practitioner students inside a doctoral program; nearly all of those rural graduates (95%) went on to practice in rural places, and students credited face-to-face intensives and faculty who stayed close by video. That evidence suggests a distinct niche: a program that is rural by design, with regional cohorts and partners, rather than a general online program that happens to admit rural nurses.

The competing programs also set expectations the new program must meet. Applicants will compare tuition, length, the number of required campus visits and whether practice hours can be completed at work. A rural program that asks for more travel or more credits than its competitors will need to show that the difference buys something, such as a project partner already committed to the student's work or a cohort of peers facing the same problems. The task force will publish a side-by-side comparison in the proposal so that the approving committees can judge the program's position for themselves.

Financial Support

The questionnaire asked nurses about barriers, and cost was the most common answer, followed by time away from work. Partner organizations offered mixed prospects for tuition support; the larger health system offers tuition assistance, while the smaller hospitals and clinics do not. Federal workforce programs for nursing and rural health, along with state loan repayment programs for clinicians who serve in shortage areas, are possible supports, though their availability changes with appropriations each year. Several surveyed nurses also reported that earlier graduate study had left them with loans, which makes them cautious about borrowing again for a degree whose return is not obvious to their employers. The curriculum cannot solve cost alone, but it can reduce the time cost: a part-time plan of study that does not require leaving one's job, and project hours that can be completed in the student's own organization, make the program affordable in time even when tuition support is limited.

Education Access for Rural Clinicians

Rural nurses' access to continuing education is itself a frame factor. Fernandez-Gendron et al. (2026) reviewed 22 studies of mobile simulation in rural health care and found that rural training needs centered on acute care, obstetric and pediatric emergencies and nonclinical skills such as leadership and teamwork, while workforce shortages, limited resources and the absence of structured training programs constrained what rural organizations could provide. Their finding that partnerships with tertiary centers and local champions made training work offers a model for our program: graduates could become the local educators and champions their organizations lack.

Accreditation and Professional Standards

The program will be designed to meet the 2021 AACN Essentials at the advanced level and to seek accreditation from the nursing accreditor that already accredits the university's master's programs, along with any substantive change review the regional accreditor requires for a new doctoral program. Keating (2015) treats accreditation standards as an external frame factor that shapes outcomes, faculty qualifications and evaluation from the start. The practical consequence is that the competency map and the systematic evaluation plan must be drafted with the curriculum, not after it.

Summary of Findings

A Biblical Perspective

Nehemiah did not begin rebuilding Jerusalem's wall until he had gone out by night and inspected it himself: "I went out by night by the Valley Gate to the Dragon Spring and to the Dung Gate, and I inspected the walls of Jerusalem that were broken down" (English Standard Version Bible, 2001/2016, Nehemiah 2:13). His plan followed what he had seen. A frame factor assessment is the same night inspection: the faculty look honestly at what is broken before deciding what to build. For a faith-based university, that honesty includes naming constraints such as cost and distance that will make the work harder.

Conclusion

The external frame factors support the need for a post-master's DNP built for rural health systems and set firm conditions on its design. The region's closures and screening gaps justify the program, its distances and costs require online part-time delivery with intensives, its regulations call for policy competence and its employers need to see the degree's value through projects in their own organizations. These findings will become the program's key elements and outcomes in the first part of the group project.

References

Beeber, A. S., Palmer, C., Waldrop, J., Lynn, M. R., & Jones, C. B. (2019). The role of Doctor of Nursing Practice-prepared nurses in practice settings. Nursing Outlook, 67(4), 354-364. https://doi.org/10.1016/j.outlook.2019.02.006

English Standard Version Bible. (2016). Crossway. (Original work published 2001)

Fernandez-Gendron, M., Lavoie, P., Charette, M., Tremblay, M. L., Grini, A., & Ledoux, I. (2026). Expanding educational access for rural healthcare professionals through mobile simulation: A scoping review. Nurse Education in Practice, 94, 104846. https://doi.org/10.1016/j.nepr.2026.104846

Keating, S. B. (Ed.). (2015). Curriculum development and evaluation in nursing (3rd ed.). Springer Publishing Company.

Liu, Z., Gao, D., Martin, T., Winegar, R., Giordano, S. H., & Kuo, Y. F. (2026). Impact of rural hospital closures on survival among Medicare beneficiaries diagnosed with colorectal, lung, breast, and prostate cancer. The Journal of Rural Health, 42(2), e70148. https://doi.org/10.1111/jrh.70148

Martinez, R. M., Perry, C. K., Izumi, S., Chipman, T. C., & Franklin, H. (2026). A regional delivery model for rural graduate nurse practitioner education: A mixed-methods evaluation. Journal of Nursing Education. Advance online publication. https://doi.org/10.3928/01484834-20260827-02

Metzger, S. L. (2026). Centers for Medicare and Medicaid Services staffing regulations in critical access hospitals: Implications for nurse practitioner practice and rural care access. Journal of the American Association of Nurse Practitioners. Advance online publication. https://doi.org/10.1097/JXX.0000000000001323

Miller, M. D., & Barut, J. C. (2026). Attitudes, perceptions, and beliefs related to full practice authority for advanced practice registered nurses. Journal of the American Association of Nurse Practitioners, 38(10), 837-846. https://doi.org/10.1097/JXX.0000000000001315

Namin, S., Heidel, R. E., Whiteside, M., Ferris, J., Wall, J. S., & McLoughlin, J. M. (2026). Rural-urban and Appalachian disparities in geographic access to colonoscopy and screening prevalence across the contiguous US. Preventing Chronic Disease, 23, E44. https://doi.org/10.5888/pcd23.260126

Smith, J. G., & Laver, S. (2026). Rural health services disruption: An evaluation of nursing's professional "positionality." Nursing Philosophy, 27(2), e70069. https://doi.org/10.1111/nup.70069