Rural Nursing Facing Unique Workforce Challenges

Efforts to train rural nurses face the difficulties found in cities and suburbs, and more.

    • September 22, 2010

In important ways, the nation’s looming nursing shortage and lack of advanced practice nurses are immune to geography, affecting communities across the land, large and small. But in other respects, geography can matter quite a bit, as in the case of efforts to increase the number of nurses serving the nation’s rural communities. As Brenda Causey, R.N., M.S.N., of North Carolina’s Asheville-Buncombe Technical Community College succinctly puts it, “You don’t get a lot of nurses moving to rural areas.” Put another way, the nurses who will serve patients in rural settings today and into the foreseeable future are likely to have grown up nearby.

Causey is one of a number of nurse leaders working on projects supported by the Robert Wood Johnson Foundation (RWJF) aimed both at increasing the number of nurses practicing in rural communities and at expanding the share of new nurses with baccalaureate or advanced degrees. Those efforts include two North Carolina programs supported by Partners Investing in Nursing’s Future (PIN). PIN is a partnership of the Northwest Health Foundation (NWHF) and RWJF to support the capacity, involvement and leadership of local foundations working to advance the nursing profession in their own communities. (Another RWJF-supported project in Kentucky, led by alumni of the Executive Nurse Fellows program, is described in a separate article in this month’s issue of Sharing Nursing’s Knowledge.)

Rural Health Challenges

Approximately one in five Americans lives in a rural area—nearly 60 million people, as of the 2000 Census. For many, medical care is miles away, and a fully equipped hospital still farther. The nurses who staff medical offices, clinics and small hospitals in these areas tend to be generalists, and need training across a broad range of areas so that they can provide primary care to patients. In cases that demand equipment and specialists beyond the reach of local hospitals, nurses are called on to help stabilize patients for journeys to larger hospitals elsewhere.

Nurses at rural medical facilities generally live in the community itself, as Causey suggests, and many face profound economic challenges in their own families. Such hardships can make it especially difficult for nurses to continue their education beyond the point at which they can be licensed and start earning a paycheck. Moreover, many potential nursing students who are the first in their families to attend college grow up without any particular expectation of attaining a college degree of any kind.

The RIBN Project

In Causey’s North Carolina, an innovative effort called Regionally Increasing Baccalaureate Nurses (RIBN) is bringing several of the state’s community colleges and four-year universities together to help nursing students in rural areas overcome economic, geographic and other challenges to earning baccalaureate degrees. In all, 56 community colleges in the state offer associate degrees in nursing, while 18 universities award baccalaureate degrees. “Our community colleges graduate and license more than two-thirds of our new nurses every year,” says Polly Johnson, R.N., M.S.N., F.A.A.N., president and CEO of the Foundation for Nursing Excellence. Every one of those graduates has an associate degree, she points out. “North Carolina data show that just 15 percent of those nurses will go on to complete a baccalaureate degree.”

In rural areas, Johnson continues, community colleges are “the primary access to post-high school education, particularly for students who can’t leave their communities for one reason or another…. Given the increasing complexity of health care, and our desperate need to increase the pipeline for future faculty, we’ve got to figure out a way to have individuals in the rural areas have access to a higher level of education, in a manner that doesn’t require that they leave their communities to go to school.”

RIBN is a two-state project run by the Jonas Center for Nursing Excellence, RWJF and NWHF’s New York-based PIN Partner. The project brings community colleges in New York and North Carolina together with four-year institutions in their respective states to forge a unified approach to admissions and curriculum so that nursing students can enter community colleges on a four-year baccalaureate track. Johnson’s Foundation for Nursing Excellence is coordinating the project in North Carolina where, after three years at the community college, students are eligible for licensure and may begin working as nurses, while simultaneously completing their fourth year of studies—sometimes online—and earning their baccalaureate degree.

One objective is to make it easier for students to get and stay on a baccalaureate track—even students who are unable to travel far from their rural homes for reasons of money or family obligations. In addition, many of the students in the community colleges are the first in their families to go beyond high school and, as Johnson observes, “We want to socialize them from day one to know that they’re on a baccalaureate track.”

“We’re getting a different group of students in RIBN,” says Causey, “a group we’ve not been able to connect with as well before: younger students. Some were tagged in high school as ones who didn’t have money to go to college, or who weren’t in the honors track even though they are very capable of succeeding academically. But they didn’t get pushed in the direction of college…. We don’t usually attract young folks but, with RIBN, we’re changing that.”

Increasing the number of baccalaureate-trained nurses is of particular importance in rural settings, Johnson adds, because four-year degrees are also a first step toward becoming a nursing school faculty member. “So there’s a bonus for the community because they have a better educated nursing workforce to provide direct care and public health services, and the community is building its own pipeline for future advanced practice nurses and faculty members.”

Once RIBN nurses graduate, program leaders expect their rural ties to remain strong. Experience has taught them that the connections to family and community that made the community college a first choice will also work to keep them providing care in the community for years to come.

Moreover, as Jonas Center Executive Director Darlene Curley, M.S., R.N., points out, nurses with baccalaureate degrees will be all the more central as health care reform rolls out over the next several years, significantly increasing the number of people with health insurance. “It is essential that we increase the number of nurses with baccalaureate degrees. Today’s nurses need the most up-to-date education to care for our aging population’s complex diagnoses, implement innovative medical technology, and play a pivotal role in health care reform.” Indeed, the new health care reform law authorizes funding for such training, with just that increased demand in mind.

Locally Devised Solutions

A second PIN project in North Carolina is taking a different approach to the same problems. Partners for Rural Nursing is a project of the East Carolina University College of Nursing’s Eastern Carolina Center for Nursing Leadership, supported by Pitt Memorial Hospital Foundation, a regional PIN partner with RWJF and NWHF. The project’s objective is to create and activate local nursing councils in rural communities to devise and implement local strategies to recruit and retain nurses. The effort is mobilizing nurse leaders with varying expertise, including work in hospitals, public health, long-term care, school nursing, community college nursing education, mental health, hospice, home health and military health.

“We tried to get the councils to look at nursing as a local challenge, not focusing on the national level or state level, but on how can they improve the workforce locally,” says Donna Lake, R.N., Ph.D.(C.), Grant Coordinator for the project. The project created local councils in two separate rural areas covering four counties, aiming for participation of 12 to 18 nurse leaders from each region. The councils met, established strategic priorities, consulted with Lake and colleagues, and then developed locally targeted initiatives.

For example, the councils devised a marketing campaign designed both to recruit new nurses and to build the pride of profession of current nurses, in order to keep them in practice. The effort included a “Many Faces and Roles of the County Nurses” brochure as well as a billboard advertisement for minority and male recruitment on a well trafficked highway—an uncommon approach, but one that Lake says has generated much positive feedback from the community.

Another council activity focused more specifically on recruitment, reaching out to high school students to encourage them to pursue careers in nursing. The effort included conversations with school counselors in each of four counties, as well as with 680 secondary students among 16 schools. A follow-up effort will feature a mentoring program that puts practicing R.N.s in touch with high school students, with the goal of helping them prepare for nursing careers.

Separately, Partners for Rural Nursing sponsored a leadership institute that brought 44 rural nurse leaders from 29 counties together for training and discussions on the traits of effective leaders, the incorporation of social networking opportunities for academic and clinical partnerships, leadership challenges and solutions in today’s health care systems, and building stronger teams as the aging nursing workforce transitions. The project mobilized nurse leaders in what Lake describes as a collaborative partnership expected to live beyond the RWJF grant.

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