According to the United States Census Bureau, about 60 million people, or one in five Americans, live in rural America. In general, rural areas are sparsely populated, have low housing density, and are far from urban centers. While urban areas make up only 3 percent of the entire land area of the country, they are home to more than 80 percent of the population. Conversely, 97 percent of the country’s land mass is rural but is home to just 19.3 percent of the total population.
According to data from HRSA.gov, as of January 2020 the United States had:
- 1,355 Critical Access Hospitals
- 4,478 Rural Health Clinics
- 3,896 Federally Qualified Health Centers located outside of Urbanized Areas
- 1,095 short term hospitals located outside of Urbanized Areas
Rural nursing is not immune to industry changes. HealthTechS3 conducted a virtual focus group with nine nursing leaders who work in rural settings to get their insight on four industry changes. Part 1 included COVID-19 and rural hospital closures. Part 2 includes tele-health and rural nursing shortages.
People who live in rural areas of the United States are more likely than urban residents to die prematurely from all of the five leading causes of death: heart disease, cancer, unintentional injury, chronic lower respiratory disease, and stroke. The CDC’s National Center for Chronic Disease Prevention and Health Promotion (NCCDPHP), states “Telehealth can help reduce barriers to care for people who live far away from specialists or who have transportation or mobility issues.”
Although tele-health in rural settings has long been identified as an important need, it has not been widely utilized in most rural settings due to the lack of reimbursement from Medicare and other payors, as well as limited cell and internet service.
With the ongoing stress of the COVID-19 pandemic on the healthcare industry, the Trump administration and the U.S. Department of Health and Human Services approved in March 2020 the expanded use of telehealth services as part of the Coronavirus Preparedness and Response Supplemental Appropriations (CARES) Act. Other payors are also now reimbursing for tele-health.
Faith Jones, Director of Care Coordination and Lean Consulting for HealthTechS3, noted in rural areas where tele-communications exist, the typical rural resident is well-versed in using these communications for such activities as shopping and communicating with family and friends. Jones noted that while there is sometimes a stigma that older Americans do not know how to use the newer technologies, this has not been her experience. She said that telehealth visits are generally well-received, regardless of the age of the patient. In fact, she said, stories of 80-plus year olds holding book clubs over Zoom is common.
The full impact of expanded tele-health on rural nursing is not 100 percent clear, but it has the potential to increase the number of patients with complex care needs both in hospitals and provider clinics.
Tele-health also has the ability to expand the role of nurses to conduct follow-up visits after hospitalization to prevent readmissions or provide annual wellness visits as part of a care coordination program.
Expanding tele-health may require additional training, competency, and certification for nurses who practice in rural settings. However, as our experts have said, that’s what makes rural nursing unique—our flexibility and willingness to learn.
Rural Nursing Shortages
According to the Bureau of Labor Statistics’ Employment Projections 2016-2026, Registered Nursing (RN) is listed among the top occupations in terms of job growth through 2026. The RN workforce is expected to grow from 2.9 million in 2016 to 3.4 million in 2026, a 15 percent increase. The Bureau also projects the need for an additional 203,700 new RNs each year through 2026 to fill newly created positions and to replace retiring nurses.
The nursing shortage is nationwide; however, shortages in rural areas are generally more pronounced than in urban settings. Factors contributing to this shortage include lower salaries, lack of proximity to colleges and universities, lack of understanding or exposure to rural nursing, and lack of employment for spouses or partners.
Although the issues are multi-faceted, Carol Kennedy, Chief Clinical Officer at Barrett Hospital & Healthcare, recommends that schools of nursing identify rural nursing as a specialty and provide more clinical time in rural settings.
Debby Renner, Interim Nursing Executive at HealthTechS3, agrees.
“I think it’s really necessary for nursing schools to look at their curriculums because I think they could graduate more well-prepared nurses, especially when nursing schools look at where their new graduates are going to work,” she said. “Nursing students planning to work in rural areas need different skills and a different way to think about their practice.”
David Harrison, Vice President of Patient Care Services at Hillsboro Area Hospital, commented on the importance of partnering with schools of nursing and helping nursing students to understand rural nursing. Harrison noted that he serves on the nursing advisory committees for a number of nursing schools and always advocates for rotations in rural hospitals. In addition to presentations about rural nursing, Harrison also recommends developing a summer nurse extern program in which a student nurse can work and be paid while developing nursing skills.
Kennedy also recommends that hospitals offer residency programs post-graduation, both to make sure that the new nurse is prepared for rural practice and increase retention.
Sarah Cordtz, who was recently the Coordinator of Quality Assurance/Risk Management at Trinity Hospital/Mountain Communities Healthcare District, added that rural hospitals should offer a robust orientation program and provide a mentor to assist in the transition to rural nursing.
Jones noted the importance of healthcare employers, including hospitals, to embrace the key messaging from theInstitute of Medicine’s (IOM) report, The Future of Nursing: Leading Change, Advancing Health, including four key themes:
- Nurses should practice to the full extent of their education and training.
- Nurses should achieve higher levels of knowledge and practice through an improved education system and professional development that promotes seamless progression with periodic competence measurement.
- Nurses should be full partners with other health care professionals in redesigning health care in the United States.
- Effective workforce planning and policy-making require an improved information infrastructure to increase data collection and advanced data analysis for decision making.
Carol Kennedy described the flexibility and importance of rural nursing this way:
“Nurses versed in the specialty of rural nursing have always been cross-trained. They may care for the heart attack patient in the morning, help deliver a baby in the afternoon, and comfort a hospice patient’s family in the evening.” This is the essence of rural nursing.
Sarah Cordtz provided these final thoughts on rural nursing and the importance to the communities in which they practice.
“Rural nursing is really an amazing place to be. You are providing services to a small community where it is common for there to be a high percentage of elderly, disabled and those who are dealing with chronic health conditions. Rural nurses need to be resilient and flexible enough to think outside of the box while providing the best care available to their patients.
Staffing shortages and lack of resources is a constant struggle, but the people you care for are your friends and neighbors. Every part of nursing gets to touch lives, but in the rural environment, it takes on even more meaning because you will be caring for your patients and their families at work and then later see those people at the grocery store, the high school events, or at the park. You know that you made a difference in their lives.”