Taylor Graham, BSN, RN, graduated from nursing school hoping to find a job in or around Boise, Idaho, the city of 200,000 where she'd grown up, or another urban center.
But when larger hospitals turned her down, she thought about Steele Memorial Medical Center in Salmon, a mountain community of some 3,000 people in the center of the state. She'd done a student clinical rotation there and had been impressed with the leadership, support for nursing and quality of care in the 18-bed critical access hospital.
The idea of rural nursing frightened Graham. She couldn't imagine being the only RN on a unit, 300 miles away from the nearest larger hospital. But Steele Memorial administrators promised she would always have manageable patient loads, other RNs working with her, and a residency program that included training, sessions with a preceptor and meetings with nurses at other facilities who also were new to rural nursing. "I knew I was going to get the support that I needed and I was going to get the opportunity to learn," she said. She decided to give it a chance. A year and a half later, Graham is still at Steele Memorial and in no hurry to leave.
Despite sporadic shortages, healthcare organizations in many rural areas, like those in the rest of the country, have seen an ease in workforce issues as older nurses have put off retirement, said rural health researcher Susan M. Skillman, MS, deputy director at the University of Washington's Center for Health Workforce Studies in Seattle. Nurses who couldn't find work in urban areas often returned to their rural roots. Partnerships between universities, community colleges and rural facilities successfully produced more new nurses who wanted to stay put.
But recently, a number of areas are reporting increased difficulty finding RNs, say those who work with rural facilities. Healthcare facilities in central Washington, eastern Idaho, Wisconsin, Illinois and Montana report higher vacancy rates and more difficulty finding experienced nurses and new grads to fill positions, according to educators, administrators and regional association directors in those states.
"Of late the nursing shortage is hitting us again," said Pat Schou, MS, RN, FACHE, executive director of the Illinois Critical Access Hospital Network, which has 53 member hospitals. Within the last six months — after several years of stability — hospital administrators are telling her they are having a hard time filling positions.
There are about 2,000 rural hospitals in the U.S., according to the American Hospital Association, including 1,328 critical access hospitals, which have fewer than 25 beds and are at least 35 miles away from another hospital. The facilities vary widely in patient population and staffing needs. "What's rural in Montana is not necessarily what's rural in Kentucky," Fahs said. Shortages depend on how many nursing schools are in the region and whether area hospitals are primarily hiring bachelor's-prepared nurses, she said.
In parts of Montana, the oil boom has driven up the price of housing beyond the affordability of a nurse's salary, Blumenthal said.
Federal workforce figures predict the country will have more than enough nurses by 2025 if demand and supply continue at the current pace. But many new graduates can't or choose not to work in rural areas because of obligations such as a spouse who can't find a job in a small community or a salary that won't support a family. Others may be intimidated by the isolation of working in a small rural facility, or don't want to drive long distances, sometimes in bad weather, say administrators and nurses who work with rural facilities.
Evidence shows adequate pay and benefits are important in attracting and keeping nurses at rural facilities, Skillman said. Programs offering tuition reimbursement have successfully attracted new graduates to rural areas, "but they don't stay very long," said Angeline Bushy, PhD, RN, FAAN, professor and chairwoman of community health nursing at the University of Central Florida School of Nursing in Daytona Beach. Bushy has worked in a variety of rural health settings and researched and written extensively about rural nursing.
Though data is sparse, a number of studies have shown rural nurses with the highest job satisfaction rate prefer rural lifestyles and come from rural backgrounds. Some rural hospital administrators said nurses with ties to the community such as a spouse or parents in the area tend to stay longer than those without connections. Programs that recruit high school students to become certified nursing assistants, then connect them with distance learning programs to earn nursing degrees, have proven successful in many rural communities, Bushy said.
Though Graham did not grow up in a rural area, her grandparents live in Salmon and she was familiar with the community. An attraction for her was the residency program for new nurses offered by Steele Memorial, she said. She turned down offers from other rural hospitals that did not have residency programs. She and other residents — all new nurses at rural hospitals — met online regularly to talk about what was happening at work with their patients and colleagues. "It's hard as a new nurse to talk about your problems when you don't have a peer group," Graham said, and those discussions, as well as support from a preceptor, helped her feel less isolated.
Some studies suggest RNs in rural areas are especially concerned about professional growth and continuing education, Skillman said. Some facilities have joined cooperatives that provide residency and training programs, or pay for training in specialties such as emergency medicine, trauma care and pediatrics. Some pay tuition or offer other support for education, encouraging nurses to get advanced degrees.
Small facilities need to figure out ways to keep nurses interested and active as their careers progress, Schou said. "Nurses like to be challenged." She suggested moving nurses into leadership roles, working with community colleges to have them teach a class, or having them create community wellness programs. Online learning programs and access to specialists through telehealth can help nurses feel less professional isolation, Bushy said.
For all these things to work, rural facilities need leaders who recognize developing and keeping a strong nursing workforce is crucial to providing quality care, which will in turn attract more qualified nurses, Fahs said. But convincing harried nursing directors and stressed financial officers they need more resources to attract and develop new nurses isn't always easy.
Partly because of a lack of solid data on what really works, and partly because resources at rural facilities tend to be scarce, few people seem to be doing much planning to address expected shortages as older nurses retire, said those who work with rural facilities. "They've had a tremendous culture shift lately," Schou said, and are now dealing with the transition to electronic health records, population health, managed care, reducing readmissions and other changes as a result of healthcare reform. "They're not doing a lot of planning" around workforce issues, Schou said.
Even with its support and strong nursing leadership, Steele Memorial seems to be constantly looking for nurses, Graham said. The pay is not enough for some to support a family, and couples can't always find work in the community for the non-nursing spouse. "It's unfortunate because we have such a great program," she said.
Her own experience has helped her grow personally and professionally in ways she never could have imagined happening in a more urban setting. She has worked with patients in labor and delivery, orthopedic, general surgery, and medical. She's looking forward to receiving training in the ED. In part because of her intense work schedule, Graham found adapting to a different type of social life one of the most challenging aspects of rural nursing, but she's now enjoying skiing on "perfect powder" snow, playing pool and helping ranchers chase down cattle.
Cathryn Domrose is a staff writer.