Time for new perspective: Rural nursing workforce 

Time for new perspective: Rural nursing workforce 
Time for new perspective: Rural nursing workforce 

After being a nurse for more than 40 years, one thing is certain: Health care and nursing are ever changing. Nearly 30 years of my nursing experience has been at critical access hospitals, so my heart holds a special place for rural nursing. Some of the greatest challenges of working in a small rural hospital have become my most memorable moments and accomplishments.

I was part of a group of rural nurses who started a nurse-owned business as leaders in the research utilization movement more than 30 years ago. I was selected to represent CAH nurses on a taskforce to increase the percentage of BSN nurses practicing in Iowa. More recently, I lead a taskforce to implement the Future of Nursing recommendations for nurse residency. During this time, I also served as chief clinical officer in a 25-bed CAH.

None of these accomplishments would have been possible without the competencies and values that were ingrained into my practice in my early years as a novice nurse. I was fortunate to have one of the best nurse leaders in the country as my first boss: Dr. Colleen Goode, one of the nation’s most recognized nurse leaders in transition to practice. She started her nursing leadership journey in the trenches of rural America, and she is someone I recognize as an influencer, mentor, and friend to this day.

I will never forget the impact she had in my development and shaping me into the nurse I have become 40 years later. She taught me to examine the facts when faced with challenges, let research guide my actions, and look outside the box for solutions. Let's look at the facts that can drive our future perspective and actions on rural nursing workforce issues.

Fact one: New nurse graduates are not flocking to rural setting to practice. In 2017, only 15.2 percent of newly graduated registered nurses entered employment with hospitals less than 100 beds, and only 6.8 percent of the group were in hospitals under 50 beds. This percentage has decreased in the past three years (NCSBN, 2017).

Fact two: Rural nurses require unique competencies while having limited resources. The need to move quickly from novice to expert has never been more critical, requiring top-notch critical thinking, adaptability to changing circumstances, enhanced bedside leadership, and teamwork to provide high-quality care in a very autonomous work environment. 

Fact three: Millennials are the most powerful and largest workforce in over 40 years (Fry, 2018). This changing work environment won’t be a strong wind with little damage, but a category 5 hurricane that changes the workforce landscape forever.

As leaders in health care, we cannot afford to bury our heads in the sand and keep doing things the way we always have while also expecting to attract, develop, and retain millennials at our rural facilities. Here a few facts about millennials in the workforce:

  1. Relationships and teamwork: Millennials want to feel a part of a team, develop relationships with co-workers, and have mentors.
  2. Work-life balance: Millenials strive to live fully both at work and in their personal life.
  3. Embrace change: In a world where we often do things because it is the way we have always done it, this generation is going to rock the boat. They love to explore how we can do things differently and more efficiently to get better results.
  4. Meaningful contributions: Millennials want to make a difference in the world. They want to contribute to the bigger picture.
  5. Career advancement: Millenials desire the opportunity to advance their career and do it quickly.
  6. Reward/recognition: Millenials expect recognition for a job well done as well as when doing their job as expected.

The good news: The core of rural nursing has the potential to appeal to this generation more than any other setting. The basic nature of our work as rural nurses – wearing multiple hats, flexing, and functioning as a team – aligns with many of the values and work expectations of millennials. Let’s take a closer look at these values and how you as a rural health leader can appeal to this generation.

  1. Relationships and teamwork: Rural health care is all about being a part of team. The typical silos found in large hospitals are not as present, and with limited staffing each person in the organization plays a vital role. It is still important to consider mentoring as a tool to build teamwork and relationships. Do you have a formal mentoring program, or do you rely on informal mentors? What programs do you have in place to socialize your nurses to the team? 
  2. Work-life balance: Have you gotten creative with care models and staffing? What requirements are you holding on to for after work hours?
  3. Embrace change: What are you doing to develop young nurses’ spirit of inquiry? Are you encouraging or demeaning their innovative ideas?
  4. Meaningful contributions: Millenials’ desire for change is an enormous gift to rural nursing. This generation offers a new set of eyes, and they are openly questioning the status quo and wanting to contribute. Are we listening to their ideas and involving them in changes so they have a feeling of accomplishment?
  5. Advancement opportunities: New graduates of millennial age will not keep working in the same role for years “waiting” for their chance to advance. Advancement does not necessarily mean an entirely new position, but rather leadership roles within the position they hold, such as inclusion on a unit-based committee or group to plan events, build new schedules, and work on policies. How do you ensure nurses have the skill set and opportunity to seek these opportunities?
  6. Recognition: What additional ways can you recognize this workforce for jobs well done? It isn’t just about special events or gifts. How do you really know what matters to them? 

Now I know what you are thinking: That’s nice, but how? I don’t have the resources. But there is a cost-effective way to make this happen while utilizing limited resources. One solution that helps facilities blend the values and expectations of millennials with the uniqueness of rural nursing is the Iowa Online Nurse Residency Program (IONRP). It is the extra edge rural facilities can offer new graduates so they can see firsthand that rural nursing is the career they want.

New graduates are asking for residency programs when searching for jobs. For years rural hospitals didn’t have such an option because of the low number of new graduates hired each year, as well as the unrealistic resources (money and people) necessary for a successful program. 

This program shows new grads that you are invested in their future and interested in providing opportunities aligned with their expectations and values. In 12 months, the program provides clinical immersion, mentorship, and enhanced professional competencies, enabling opportunities for advancement, meaningful contributions, and exploring change projects.

Even better, the program outcomes speak for themselves. In a recent article by Wilson, Weathers and Forneris (2018), the three years of program implementation had impactful results in rural facilities over a 12-month time interval. Significant improvement in confidence with communication and teamwork as well as increased competency in quality improvement, evidence-based practice, communication, and leadership were reported. There was also a reported decrease in negative safety practices.

Now is the time for rural facilities to let the facts and evidence drive their decisions to use best practices such as IONRP to help recruit, develop, and retain high-quality nurses. It is imperative for the health of rural America. Choose to be the leader that inspires, mentors, and develops new nurses to sustain the rural workforce, like I was so fortunate to have experienced more than 40 years ago.


NRHA commissioned the above piece from Iowa Online Nurse Residency Program, a trusted NRHA partner, for publication within the Association’s Rural Health Voices blog