Nursing in Rural Areas: Challenges, Shortages & Solutions

Introduction: Rural Nursing in Crisis

Rural nurses are particularly endangered by the current and worsening shortage in nursing. Rural nursing is already beset with issues that range from a lack of a clear professional practice system and the need for larger incentives for nurses to work in rural areas, to a general unwillingness among nurses to live in these areas and the foreseen depletion of the rural nursing supply. Possible solutions and approaches have been proposed, though no single or simple answer has emerged.

Approximately 20%, or 54 million U.S. residents, live in locations categorized as rural (Bushy, 2006). These residents are distributed across 80% of the nation's total land area. About 99 or fewer residents occupy every square mile in these areas, and they experience the shortage of nurses more acutely than residents in urban areas. Moreover, rural residents generally have lower annual incomes, less education, and poorer health status than their urban counterparts. Local health care providers cannot compete with the wages, start-up bonuses, and benefits offered by urban facilities. The situation is even more difficult in frontier areas where the population is smaller, particularly regarding wages. Financial constraints also limit educational opportunities in small hospitals, and an inadequate number of nurses hampers the recruitment of physicians, thereby restricting local residents' access to care. These residents must spend more to see specialty or even basic health care providers in urban areas for services that are not found or are inadequate in their communities (Bushy).

Nurses who consider working in rural areas need to understand the scope of nursing practice in those settings, the community's norms and behaviors, and the consequences of choosing to work there (Bushy, 2006). They need to recognize the necessity of new changes in education and existing systems, which require multi-dimensional strategies and partnerships among educators, researchers, rural communities, and policy makers. All of these partners are equally necessary to confront the challenges of rural nursing, and there is no single or simple solution to its inherent problems. The rewards, however, are great for those who remain dedicated, as long as they view the career realistically (Bushy). As one survey participant observed, "a rural nurse lives and breathes rural air… there is dust and dirt and mud and grit in her work" (Litchfield & Ross, 2000).

Workforce and Employment Issues

A national survey conducted among 84 nurses in New Zealand in 2000 identified workforce and employment issues in rural nursing practice (Litchfield & Ross, 2000). The mean age of the almost-entirely female respondents was 46.3. Almost half were in their 40s, and 30.6% were 50 years old or older. Most respondents were from New Zealand or Europe (89.4%). All held basic general nurse registration, but few had formal or specialty preparation in rural nursing or any of its components. Only 5.9% held a bachelor's degree. More than half lived in rural areas and made limited use of computer technology. Workforce issues identified included recruitment and retention, education, and career structure. Nurses' work was fragmented, and a lack of a clear professional practice system in the contemporary rural health service context was identified as a pressing concern that must be addressed (Litchfield & Ross).

Knowledge, Skills, and Policy Interventions

The Health Department of Western Australia noted that "nurses working in rural and remote areas of Western Australia are often sole practitioners… expected to function at a higher level than nurses in metropolitan areas" (DEST, 2001). Medical practitioners are reluctant to work in small rural areas for these reasons, while health services are simultaneously unable to employ sufficient health professionals because of the associated costs. The knowledge and skills required in rural nursing are determined by employers and the particular needs of the local community, both of which require rural nurses to possess a broad knowledge and skills base. Dedicated rural nurses must practice in extended roles in order to fill service gaps and ensure that care continues to exist in these communities (DEST).

A 2006 national and international survey revealed the importance of substantial financial incentives in motivating nurses to work in rural areas (Blaauw et al., 2010). The study examined rural nurses from Kenya, South Africa, and Thailand using discrete choice experiment (DCE) data, a methodology that has proved reliable in human resource research in low- and middle-income countries. A 10% increase in salary was not found to be a strong incentive. Improved housing and accelerated promotion were somewhat stronger motivations. Preferential access to training and career advancement opportunities were far more powerful non-financial encouragements. Changes in management culture were less important to South African respondents, who were young graduates preferring varied management styles — some wanting personal and supportive managers, while others opted for a traditional hierarchy that offered discipline and proper use of resources (Blaauw et al.).

These findings call for policy interventions appropriating considerably more financial resources than are currently provided in these countries (Blaauw et al., 2010). Preferential training was attractive for its future economic potential. Certain benefits, such as car allowances in South Africa, became enormously appealing due to the social prestige associated with them. Nurses who came from rural areas were also found to be more likely to choose a rural placement (Blaauw et al.).

Conclusion and Recommendations

Nurses in rural areas confront workforce and employment issues in the form of a lack of a rational professional practice system. Few hold formal or specialty preparation for rural nursing. Employers and local communities determine the knowledge and skills that rural nurses must possess, yet health services are often unable to afford the costs of adequate hiring. Large financial incentives are needed to attract nurses to rural areas; salary increases alone are insufficient, though non-financial incentives such as preferential training and career advancement are more attractive.

The responses of homecare nurses in Western Quebec reflect a need for a palliative homecare team and cohort-specific professional development as a peer support network and provider of accessible education and training. Rural health clinics have demonstrated the ability to maximize the use of health care professionals — particularly registered nurses — alongside effective organizational culture and managerial systems and techniques. South African registered nurses view working in rural areas as beneficial but stressful, while rural living is generally viewed as neither quality, appealing, nor enjoyable. The general shortage of nurses is felt most acutely in rural areas as baby boomers retire and active nurses migrate to urban employment. Proposed solutions include more responsive education programs and curricula, admission of students likely to work in rural areas, and best practices to recruit and retain them.

A clinical career structure for rural nurses and a framework for their advancement should be clearly defined, specifically within the context of community health needs. A recruitment and retention strategy should be established, and employers should review strategies to develop the specialty practice of rural nursing, a structure for service delivery, and provisions for or access to information technology. It is necessary for rural nurses to acquire a broad knowledge and skills base. Preferential selection of rural students may be an effective policy to adopt. A palliative homecare team and cohort-specific professional development in palliative care can respond to the needs identified by homecare nurses in Western Quebec. Rural health clinics have shown they can maximize the use of their health care professionals, and organizational culture and management systems will provide further positive inputs. Focus should also be directed toward students born in rural areas and students from rural parts of the North West province, as they are statistically more likely to choose rural careers. Proactive approaches to the perceived shortage of rural nurses should include the expansion and support of nursing education programs, admission of students likely to opt for a rural career, rural-relevant curricula to prepare them for rural challenges, and best practices for recruitment and retention.

References

Arnaert, A. et al. (2009). Homecare nurses' attitudes towards palliative care in a rural community in western Quebec. Journal of Hospice and Palliative Nursing, 11(4). Retrieved from http://www.medscape.com/viewarticle/715133

Blaauw, D. et al. (2010). Policy interventions. World Health Organization. Retrieved from

Bushy, A. (2006). Nursing in rural and frontier areas: Issues, challenges and opportunities. Harvard Health Policy Review, 7(1). Retrieved from http://www.hcs.harvard.edu/hhpr/publications/previous/06s/Bushy.pdf

CREHS. (2009). Nurses' attitudes towards working and living in rural areas. Consortium for Research on Equitable Health Systems: Centre for Health Policy. Retrieved from http://www.crehs.shtm.ac.uk/downloads/publications/SA_cohort.pdf

DEST. (2001). Knowledge and skills required by rural nurses. Department of Education, Science and Training: Commonwealth of Australia. Retrieved from http://www.dest.gov.au/archive/highered/nursing/pubs/rural_nurses/3.htm

Litchfield, M., & Ross, J. (2000). The role of rural nurses: A national survey. Centre for Rural Health: New Zealand Ministry of Health. Retrieved from http://www.moh.gov.nz/moh.nsf/pagesmh/4992/$file/Role_Rural

Ortiz, J. et al. (2010). Contextual correlates of rural health clinics' efficiency: Analysis of nurse practitioners' contributions. Nursing Economics. Jannetti Publications, Inc. Retrieved from http://www.medscape.com/viewarticle/729490

Skillman, S. M. et al. (2009). Threats to the future supply of rural registered nurses. Policy Brief: Rural Health Research and Policy Centers. Retrieved from http://depts.washington.edu/uwrhrc/uploads/Rural_RNs_PB_2009.pdf