New RNs Lack of Geographic Mobility Poses Challenge for Rural Health Care

Study from RWJF-supported RN Work Project is the latest examining the factors in nurses' decisions about their jobs.

    • December 18, 2011

Common wisdom about nursing is that one of its great advantages as a profession is its geographic mobility. Wherever people need to get or stay healthy, nurses are likely at work. But a new study from the RN Work Project, a 10-year research effort funded by the Robert Wood Johnson Foundation (RWJF), finds that in actual practice, nurses are less geographically mobile than are other professionals with similar levels of education. The study’s authors warn that this lack of mobility has serious implications for access to health care for people in rural areas.

The study is one of a dozen to date from RN Work Project researchers Christine Kovner, PhD, RN, FAAN, of New York University, and Carol Brewer, PhD, RN, FAAN, of the University at Buffalo. It is a part of a longitudinal study of newly licensed RNs (NLRNs) the researchers began in 2006 to explore a series of issues related to nurse turnover rates, including job satisfaction, organizational commitment and work preferences.

In their latest study, Kovner and Brewer find that more than half of newly licensed RNs (52.5 percent) work within 40 miles of where they attended high school. Even more nurses reported working in the same state in which they attended high school. Nearly four in five of the nurses surveyed who held associate’s degrees (78.7 percent) and more than three in four of those with bachelor’s degrees (76.8 percent) practiced in the state where they had attended high school.

This lack of mobility is higher for nurses than for most other professionals. According to the study, six in ten professional workers with an associate’s degree (60.8 percent) and 53.3 percent of workers with a bachelor’s degree lived in their state of birth as of the 2000 census. Among RNs with bachelor’s degrees, 61.6 percent aged 20 to 39 were living in their state of birth compared with 56.8 percent of comparable professionals in other fields.

Kovner and Brewer say that nurses’ relative lack of mobility means that hospitals and other health care institutions must rely heavily on locally trained RNs and that they may find it difficult to recruit nurses when there are not enough already in the local area. That can be a particular challenge in rural areas, where fewer schools of nursing are stocking the pipeline of local nurses.

“Given the strong tendency for nurses to practice close to where they attended nursing school and to attend nursing school near where they graduated high school, it’s not surprising that parts of the country with few or no schools of nursing are struggling to find nurses,” said Kovner. “We did not investigate the reasons for nurses’ lack of mobility, but this reality suggests that more needs to be done in areas with few nursing schools in order to meet the health care needs of those communities.”

Policy Solutions

The researchers recommend a number of policy approaches to expand the supply of nurses in underserved areas, including:

  • Targeted educational supports, such as scholarship and loan forgiveness programs, to encourage local students to pursue nursing;
  • Expansion of nursing education programs in underserved areas;
  • Reconsideration of university admission and financial aid policies; and
  • Financial incentives to attract nurses to underserved areas, along the lines of those offered by the National Health Service Corps and the Area Health Education Centers.

Understanding the Forces at Work in Nurses’ Work Lives

Each of the RN Work Project studies to date has examined a different aspect of nurses’ working lives, seeking to better understand what shapes decisions nurses make about their employment paths and what that means for the nursing workforce as a whole.

“Conventional wisdom has always been that a lot of new graduates of nursing schools leave nursing, or at least leave hospital jobs, early in their careers,” Brewer says. “We wanted to know if the conventional wisdom was right and, if it was, why nurses leave and what we can do about it.” Previous studies had identified the factors at work in the decisions new nurses made about whether to stay in their jobs. But Kovner and Brewer concluded that longitudinal research—surveys examining nurses’ views and choices over a period of time—were critical to understanding what was really at work. For example, nurses who expressed job dissatisfaction early in their first hospital jobs might feel differently one year later. Or they might have left their jobs for other nursing positions—elsewhere in the hospital, or outside the hospital. Or they might have left the profession altogether. By tracking these nurses over time, Kovner and Brewer hope to understand the interplay between early-career nurses’ views about their jobs and their longevity in the profession.

RN Work Project studies to date have covered a host of topics in this area:

  • A 2009 study focused on factors influencing job satisfaction and their causes among NLRNs. For nurses who were dissatisfied with their jobs, these factors were stress, physical and mental demands, and compensation. Nurses who were generally satisfied also found the physical demands of the job to be a burden, but cited competitive salaries, health insurance benefits and flexible scheduling as positive factors.
  • Another 2009 study compared the demographics, attitudes and work experiences of second-degree nurses—those who earned a nursing baccalaureate after earning a degree in some other field—with new nurses who followed the more traditional path of receiving their first baccalaureate degree in nursing. Kovner and Brewer found that the second-degree nurses were more likely to work in management positions, and more likely to be male, non-white, married, and to have children living at home.
  • A 2010 study compared and contrasted the views of several generations of nurses—those from the Baby Boom (born between 1946 and 1964), “Generation X” (1965 to 1979) and “Generation Y” (1980 to present). Among other things, the researchers found that RNs from Generation Y were more likely than others to have graduated from a baccalaureate nursing program, to be working in an ICU, and to be working 12-hour shifts and night shifts.
  • A 2011 study explored non-staffing work environment factors that early-career RNs said had a bearing on the quality of care that nurses felt patients received. The study pointed to the importance of improvements in nurses’ physical work environment, the role of workgroup cohesion and nurse-physician relationships, among other things.
  • A 2011 study showed that over and above intention to stay, a direct factor affecting turnover was back strains and sprains, indicating the importance of lift policies.

Other studies have looked at nurses’ commutes to work and how that affects whether they stay at their jobs, new nurses’ views on quality improvement education, and the factors critical to nurses’ intention to stay at their jobs.

Kovner and Brewer have more studies in the works, some drawing on data they’ve already gathered, and some that will rely on future surveys. One upcoming study will examine data collected from early career nurses during the height of the recession to see how nurses’ views on job satisfaction and their intention to stay in their current jobs might be affected by the economy. Another will examine the incidence of verbal abuse experienced by new career nurses, both from colleagues and from physicians.

“One of our major interests,” Brewer says of the upcoming studies, “is to look at the change in the factors that affect nurses’ views about their jobs over time. We want to see how their views change, and how that changes their work behavior. Common sense would tell you that if their overall job satisfaction increases, they’d be more likely to stay in their jobs. But we have a lot of data and a lot of specific factors that we’re exploring, and we’ll look at all of them to see how they really interact.”