Green Acres
Looking for a job?
Think about moving to the country
 

By Barbara Tone, RN
Illustration by Malcolm Garris/PhotoDisc
March 25, 1999

Recruiting and retaining qualified nurses is always a challenge. Recruiting and retaining qualified nurses in rural areas can border on the impossible, especially given the economics of health care.

With 55 of the 58 counties in California considered entirely or partially rural and rural areas accounting for 80 percent of the state’s geography and 13 percent of its population, the need for qualified rural nurses in California is an ongoing problem. "Our resources get really stretched," said Mark Clarke, RN, director of nursing for Del Norte Clinics Inc., based in the town of Olivehurst in Yuba County. "You have to be ready to deal with any kind of problem—physical, social, and educational. It can be a real struggle to meet all the needs of our patients."

"If you have one nurse missing in a small specialty department, that is sometimes a third or a fourth of the entire staff," said Dorel Harms, MS, RN, vice president of professional services for the California Hospital Association and a former rural hospital administrator.

Lengthy vacancies

Rural facilities took significantly longer to fill nursing vacancies than did urban facilities for 15 out of 22 nursing specialties, according to a survey released by the American Organization of Nurse Executives in February. While the range of days varied, rural areas took up to 60 percent longer to fill vacancies than urban areas. The shortest recruiting time in rural areas was for new nursing graduates at 21 days, compared with 14 days in urban areas. The longest recruiting time in rural areas was for clinical nurse specialists at 150 days, compared with 90 days in urban areas.

Nursing administrators at rural facilities say the survey reflects the realities they face. They describe a revolving door for new grads. With many urban facilities reluctant to hire nurses right out of college, and rural areas hurting for help, new graduates often take rural positions just long enough to get the experience needed to get an urban job. "It seems like ‘in new grad, out new grad.’ We feel like a training ground," said Ann Kapernick, RN, a nursing administrator for 80-bed Ridgecrest Regional Hospital in Central California. "We just never seem to get ahead with the need to fill new vacancies."

Varied barriers

The barriers to luring nurses to rural areas are as varied as the nurses themselves. In many cases, wages are the problem. While pay has increased in recent years, particularly for nurse practitioners, for many nurses it’s often not enough to offset the lifestyle differences of living in a rural area.

If the nurse has a family, it can be difficult to impossible for a spouse to get employment in a small town. If the nurse is single, the lack of social activities, and people with whom to socialize, may be a deterrent. "Women still comprise 90 percent of nurses," Harms explained. "If they are married, there are no jobs for the husband. If they are single, there is almost no social life."

Nurse Practitioners Are An Exception

Nurse practitioners are an exception to the severe rural-RN deficiency. While still more difficult to fill than urban vacancies, there are bigger "carrots" to help recruiters fill NP slots. The increased salary, challenge, and independence help draw nurse practitioners out of the city. The more than 200 federally designated rural health centers in California must employ at least a half-time "mid-level practitioner" (nurse practitioner or physician assistant). For the time being, designated rural health centers are still on cost-based Medicare reimbursement, enabling them to pay competitive salaries to practitioners.

Although challenged and stimulated, rural nurse practitioners sometimes face an uphill battle to win physician acceptance. Although many rural physicians are progressive, supportive, and encouraging, there are still many who have difficulty with any advanced practice role for nurses. The acceptance of nurse practitioners is a significant issue in some rural areas, according to Jeff Bauer, PhD, of Hillrose, Colorado, a health futurist, medical economist, and author of Not What the Doctor Ordered, a book about nursing and allied health alternatives in health care. "I think rural doctors—not all of them, of course—tend to be a bit more traditional and treat nursing personnel in a more subservient way. In rural areas, you are more likely to be working with doctors who want to ‘put you in your place,’" he said.

For other nurses, the lack of access to academia or continuing education is an issue. Stepping up the academic ladder, whether from associate degree to bachelor’s, from bachelor’s to master’s—or even getting in-depth continuing education—is much more difficult if the nearest urban area is 200 miles away.

Finally, the breadth of knowledge required of a rural nurse can be intimidating. For nurses who came of age in the era of specialization and might have 10 years of oncology or rehab experience, the call to deliver a baby, deal with a dialysis patient, or assist in the OR can be frightening. "Our nurses have the challenge of having to wear a lot of hats," Kapernick said. "That can be very difficult if you’re not a ‘seasoned’ rural nurse."

Getting creative

With all these obstacles to overcome, rural recruiters have become frustrated—and very creative. Recruiters have hired traveling nurses, foreign nurses, temporary agency nurses, and new grads. They have run ads, created per diem pools, formed affiliations with nursing schools and preceptorship programs, recruited through state loan repayment and scholarship programs, and more and more frequently "grown their own."

One way to draw nurses to rural areas is to pay for their education, and rural facilities get help from the state for that. The Registered Nurse Education Fund, part of the state Health Professions Education Foundation, supports education for nurses who are willing to work in medically underserved areas, both urban and rural. Five dollars from each RN license renewal goes into the fund. Since 1990, the fund has provided scholarships or loan repayment to 750 nurses who have agreed to work in an underserved area for two years after they graduate. Angela Smith, acting executive director of the program, reports that many nurses are already working in underserved areas when they apply. Most of them, however, come from urban, rather than rural, underserved areas.

Another recruitment tactic involves four- to eight-week preceptorships. "The idea is that if you get enough nurses and expose them to the rewards and challenges, a few of them might stick around," explained Kathleen Kirby, program coordinator for the Rural California Nursing Preceptorship Program, based at California State University, Chico. Kirby is responsible for the Northern California area and has gone as far south as Long Beach to recruit students into the program. According to Kirby, the program places 75 nurses a year. Sixty-five per cent are offered jobs, and about half of those accept; many of those who accept do so because of the loan repayment program. "The loan repayment is a big carrot, but still a short-term answer," she said.

To get around the problem of short-term employment, the "grow your own" strategy has gained favor. Employers identify promising nursing assistants or LVNs living and working in the community and pay for their further education. While initially expensive, many recruiters say they’ve found it a better long-term investment.

Harsh realities

Among the problems that plague rural areas, the economic realities of health care loom large. When cutbacks occur in urban areas, there are more facilities to share the burden. In a rural area, there may be one hospital or one clinic. "We have to cover people who fall in the gaps," Clarke said. "We have lots of working poor with no insurance."

When the Balanced Budget Act of 1997 was passed, rural hospitals had just begun to recover from Medicare’s 1983 prospective payment system for inpatient care. Skilled nursing and home care were still being reimbursed under a cost-based system, allowing rural facilities to shift costs to these areas somewhat. But the first phases of the ’97 legislation, implemented in July 1998, significantly altered payment for these areas and have left providers reeling. "Many of them were hit really hard," said Jeff Bauer, PhD, a health futurist and medical economist in Hillrose, Colo. "Home health agencies that were thriving in 1996 were mere shadows by the end of 1998."

Crystal ball

As for the future of rural nursing, experts say changes in the nursing shortage, the legislative winds in Sacramento and Washington, the general state of the economy, and technological advances will all play a part.

On the bad news side, there are dire predictions of an increased nursing shortage. BSN enrollments have been dropping for the past four or five years, and there is grave concern in some circles about the future availability of nursing school faculty. Kenneth Lowrance, MS, NP, RN, president of the Board of Nurse Examiners in Texas, has been looking at the trends and predicts a shortage worse than that in the 1970s. "The average age of current nursing school faculty is about 53 years old," he said. "Most of them will retire in the next 7 to 10 years. Many of the advanced practice nurses who might have gone into education are now going into practice. It’s going to be difficult to find qualified faculty, which will further limit enrollment."

On the good news side are the enormous changes under way in telemedicine. "This is a whole new realm," Bauer said, "and it will drop a lot of barriers." Ridgecrest Regional Hospital is already pursuing a grant for on-site telehealth education, which would enable it to "grow their own" nurses. Bauer predicts that education at all levels will be more available, consultations will be a keystroke away, nurses will be able to interact with far-away colleagues more easily, and satellite examinations will open a whole new world. "The new medical scene is in outpatient and telemedicine," he said. "I’m very optimistic about rural health."

Whatever the future brings, rural nurses seem tailor-made for the challenge. They’re so used to overcoming obstacles, wearing multiple hats, and switching gears, that the future may seem to them a lot like the past.

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