Out in the Alaskan bush, Jo Andrew, regional nurse manager for public health nursing, felt uneasy when an 18-month-old child didn’t respond to an eye-screening test. An ophthalmologist soon diagnosed the child with congenital corneal problems. Without immediate surgery, the baby would have lost her sight permanently.

Andrew set up the referral for the ophthalmologist and the surgery. It’s one of her fondest memories from in-the-field public health nursing. If she hadn’t followed up on her concern, there would have been no help for the child.

For the past three decades, Andrew has eschewed the lower 48 states for the good life in Alaska. "I don’t think I’d live anyplace else. The people are easier to get to know," she said. Fishing, boating, winter sports, hunting, dog racing and native dancing keep the locals busy.

Andrew supervises a team of nurses that travels to remote villages in propeller planes. They coordinate with health aides in the villages to set up appointments for well-child exams, Medicaid screens, food-borne illnesses, communicable diseases such as TB, tobacco cessation and more. The nurses devote most of their time to children, but administer adult flu shots and make home visits for high-risk families, Andrew said

Familiarity doesn’t breed contempt in most rural communities. The Alaskan villagers are kind to the nurses, who visit every other week, Andrew said.

That’s not to say life is free and easy in the country. Rural health care providers have been challenged by staffing shortages—especially in key specialty areas—for years, long before today’s nursing shortage began to spark concern about a looming national crisis in health care.

The experiences of rural care providers and nurses may provide some lessons for their counterparts in big cities who increasingly are facing the same staffing challenges, despite the bright lights and opportunities that have served as a magnet for millions of young, rural Americans during the past few decades. In any case, the rich experiences of rural nurses serve as a reminder of why so many have been drawn into the profession and remain committed to it.

Rural nursing tends to attract nurses who prefer to do it all rather than specialize. The opportunity to try innovations such as telemedicine and to develop symbiotic relationships with physicians and the community are among the many advantages that can keep them hooked.

Together we overcome
Short staffing has become such a constant that specific recruitment and retention strategies have evolved.

"The nursing shortage in rural areas is a community issue," said Mary Becker, senior vice president of the Missouri Hospital Association. "The hospital in rural areas is a community hub. The nurses there have a real opportunity to rally the community—a better opportunity than in urban areas.

Anna Engman, chief operating officer and director of nursing at Mayers Memorial Hospital, a 22-bed facility in Fall River Mills, a town in remote northeastern California, said physicians and nurses alike pull long shifts, come in on weekends, pay home visits and treat each other with respect.

It’s a "we’re all in this together" mentality.

Retention and recruitment strategies focus on community involvement rather than on urban solutions, such as signing bonuses and other fixes. Precepting students for a month or six weeks is one strategy, but seldom leads to long-term employees, said Kathleen Kirby, rural nursing program coordinator at California State University, Chico.

The "grow your own" technique with community colleges and recruitment at high schools tends to work best, Engman said. "We’re encouraging regional collaboration, such as getting communities to define what their region is, and then we pull high schools, economic development agencies and chambers of commerce to the table," she said.

On the downside, many rural hospitals are closing, said Engman, because Medicaid and MediCal reimbursements tend to be low. The corporate sponsorships for urban hospitals do not extend to rural facilities.

A number of nurses in rural areas will contend with a three- or four-hour commute to St. Louis for the specialization possible there and, perhaps, a higher salary.
"We can’t keep taking nurses from one area to another. Overall, the patients are not well served," Becker said.

Although salaries tend to be higher in urban areas, the purchasing power often is less than in rural areas. The median salary of a staff RN in Dallas is $43,525, compared to $38,755 in Killeen, Texas. But in Dallas, you need to earn only $37,308 to have the same purchasing power in Killeen.

So the hardships tend to revolve around funding for hospitals and lack of access to urban niceties. Those who choose to live in the wilds often do so for enduring reasons, however.

The training program for public health nurses in Alaska yields good returns in that the itinerant nurses tend to stay, Andrew said, but that could change as nurses age. Already, they mirror the national average age of 45, with few younger nurses entering the public health fold in Alaska.

"We surely do need more help," Andrew said. "It’s harder and harder to get an experienced public health nurse."

Andrew prefers nurses with bachelor’s degrees for PHN I, or trainee, positions.
A nurse with an associate degree or a diploma nurse must have learned public health nursing elsewhere in the United States before Andrews will train them.

The PHN II and III designations denote the nurses who’ve been in the trenches. All the PHNs in Alaska are employees of the state. There are salary adjustments for those whose hub is in the bush, where costs for everything run higher.

Opportunity for NPs
Nurse practitioners, as well as many rural staff nurses, say there is nothing else they would rather do. Therese Hidalgo, FNP, RN, practices at Presbyterian Family Health Care Center in Belen, N.M. She moved there from Santa Fe when she and her husband chose to raise their three sons in the country and live closer to his parents. The change was drastic, Hidalgo said. After years of working with new mothers, suddenly she was taking care of older people and male patients. "But it was probably the best thing that could have happened to me," she said.

Unlike RNs, advanced practice nurses are plentiful in most states. But many rural areas don’t know what to do with them, and nurse practitioners who want to work in a rural area must have a job offer, said Joel Davidson, MPA, MBA, executive director of the Southwest Wisconsin Area Health Education Centers.

Many times, though, the jobs aren’t there. "There are places that could use them, but no one is willing to work with them," Davidson said.

Even Hidalgo, who knew the physicians at her clinic because she had worked with them as an RN, said that at first they were unsure how to use her training. But in the end, they were anxious to have her because they needed relief in the urgent care area, she said.

Eventually, she let the physicians know she wanted to take on primary care medicine. Now she takes her turn at urgent care. The physicians consider her the expert on women’s health care.

Carol Schauf, MSN, FNP, said she’d always wanted to work in a rural area. "You know how things just call you, like the mountains or the beach?" said Schauf, who works at Cross Timbers Community Health Clinic in De Leon, Texas. "I always wanted to live in a place where you could see the sun rising, not just over your neighbor’s houses at nine in the morning, but over the horizon, and you would see it setting over the horizon."

Schauf said she works well with the physicians and physician assistants. She loves her patients, who often address her as "doctor." Even after she informs them that she’s a nurse, they tell her, "I know, but you’re my doctor."

But Schauf said she wants to return to city life again for a while. She misses the pulse of the city.

She might feel differently, she said, if she weren’t the only nurse practitioner in the community. A group of rural nurse practitioners meets in Abilene, but that’s nearly 100 miles away.

Cheryl Pedersen, MPH, a nurse consultant at the Rural Wisconsin Health Cooperative in Sauk City, Wis., said she expects attitudes will expand as physicians and patients realize the value of nurse practitioners in rural areas.

Nurses who do decide to stay in rural areas often don’t regret their decision.

Mobile intensive care nurse Randi Holscher, PHN, RN, a nurse supervisor at Mayers Memorial Hospital, moved to Fall River Mills in Northern California because she and her husband decided to raise their children in a small town, wanted to be near her husband’s parents and loved the beauty of the area.

Before making the move 10 years ago, she worked as an emergency room nurse, which helped prepare her for the variety of rural nursing, she said.

A typical 12-hour shift for her might include caring for 20 emergency room patients, seeing eight new admissions and delivering a couple of babies. Or she might have no new patients at all.

"I love delivering babies. I love working in the emergency room. I love taking care of critical patients. But I don’t think I’d want to do any of it all day long," she said. "Rural nursing is its own specialty because you have to be flexible."