Rural Nursing Shortage - RN to BSN Portfolio



Rural Nursing Shortage

Jamie Kruger

Ferris State University

Abstract

The nursing shortage is analyzed from a rural perspective. Rural nursing theory and relevant social theories are considered in an effort to explain the worsening rural nursing shortage. Meaningful themes of rural nurse job satisfaction, staffing ratios, and aging workforce are examined along with other stakeholders, such as rural communities, nursing schools, and government involvement. Likely consequences are discussed in addition to quality and safety issues that will influence rural nurses in achieving higher job satisfaction.

Keywords: rural nursing shortage, rural nursing theory, nurse job satisfaction

Rural Nursing Shortage

The world is in the midst of a nursing shortage, with predictors saying it will only get worse. Nurses are the largest sector of the health care worker population, and there is a projected shortage of over one hundred thousand registered nurses by the year 2030 (Juraschek, Zhang, Ranganathan, & Lin, 2012). This shortage, while caused by many factors, needs expert attention now in order to stop it. This lack of nurses will be most acutely experienced in rural areas where there is already a health care crisis (Bushy, 2006).

Rural areas by definition are sparsely populated. According to Bushy, rural regions are those that have “ninety-nine or fewer people per square mile” (Bushy, 2006, p. 17). Health care facilities in rural regions are already finding it a challenge to recruit and retain nurses, due to the inability to compete with urban centers that offer sign on bonuses, flexible work hours, higher wages, and better benefits (Bushy, 2006).

The rural health care crisis has its foundation of many causes. Rural areas tend to have populations that are older, many of whom have multiple chronic disease (Burrows, Suh, & Hamann, 2012). Rural locales are often poor with high levels of unemployment, and many residents living in poverty (Bushy, 2006). Many residents are under or even uninsured, and more of these individuals are obese or abuse tobacco than their urban counterparts (Bushy, 2006). From an environmental standpoint, the very nature of rural living can inhibit residents from seeking care due to the lack of proximity to health care facilities (Burrows et al., 2012).

The complexity of the rural dweller coupled with the nursing shortage makes for a perfect storm. The younger generation of nurses need to become involved in solving this problem to alleviate the shortage. If the shortage reaches the maximum highpoint as predicted, these nurse will be forced to work in environments with staff shortages, and higher patient/nurse ratios, which are proven to be harmful (Honan Pellico, Djukic, Tassone Kovner, & Brewer, 2009). Likewise the older generation of nurses, those that will be retired by the year 2030, should also have a keen interest in this problem. If these nurses stay in the rural areas in which they work, they will be the health care consumers that will be on the receiving end of the shortage.

Several points of view address the rural nursing shortage. Firstly, how must the different health care agencies recruit and retain their nurses if they have little resources to do so, and when they are not able to improve work environments like urban facilities? Secondly, nursing schools have a responsibility to educate new nurses on rural nursing, effectively preparing them to work in isolated areas where they are expected to work as generalists. Thirdly, there needs to be government level change that addresses the rural nursing shortage, making nursing education more accessible, more affordable, and stimulate nursing growth in rural areas.

Applicable Theories

Rural Nursing Theory

Rural nursing theory has many concepts that seek to explain the relationships and choices that pertain to rural healthcare. Most concepts are from the patient’s perspective, but one seeks to explain the interactions from the view of the health care worker. This concept is that health care providers lack anonymity in a rural setting, experience isolation, and experience role diffusion (Lee & Winters, 2004).

Rural nurses that work in the communities where they have made close relationships with their community are often held in high regard by the inhabitants. While this is a beneficial trait, this can also be a source of despair for the nurse. These nurses often live with a sense of transparency, where the lines between their professional and personal lives become distorted (Bushy, 2006).

Rural areas are small, tight knit communities where social bonds between inhabitants have matured over generations. When the nurse comes from outside the community, he or she will realize several different things. The nurse will soon grasp that he or she is seen as an outsider. With this outsider status, the nurse will have a more difficult time relating to patients from the new community, making for a strained nurse-patient relationship (Crow, Conger, & Knoki-Wilson, 2011).

Nurses can also experience a sense of isolation in rural areas, not just social but professional (Conger & Plager, 2008). This isolation from like minded peers can prove to be enough of a motivator to relocate to a more urban area (Conger & Plager, 2008). Additionally, one way to become more connected with the outside world is through the use of the internet, but in rural locations this may even prove to be difficult. Nurses that do not have a peer to discuss things with, either in person or through distance communication, feel a sense of loneliness that influences their decision to leave a rural area (Conger & Plager, 2008).

When working in a rural area, the nurse often becomes adept at being a generalist, competent in wearing many hats (McCoy, 2009). The concept of “jack of all trades, master at none” may apply, when the rural nurse has no opportunity to specialize. This lack of opportunity to hone in on one skill may be a motivator for the nurse that wishes to specialize to evaluate his or her professional ambitions, and seek employment in an urban setting where this can be accomplished (McCoy, 2009).

Contingency Theory

Contingency theory is an organizational theory that addresses the internal and external limitations that occur within an organization (Sanders, 2010). Core concepts identified are the vigor of the external environment, complexity of the organization’s tasks and the technology used, and the professionalization of the workforce (Sanders, 2010). Nurses employed in hospitals can identify with these concepts as in hospitals they are taking in patients from the outside, doing complex tasks with different technology, and they desire to be seen as professionals. This is no different in rural locations. With this theory, the issue of recruitment and retention can be addressed.

One method of recruiting and retaining registered nurses is through programs like the Magnet Recognition Program. The Magnet Recognition Program is designed to ensure recipients employ nursing excellence through leadership, empowerment, professional practice, innovations, and by showing empirical outcomes (American Nurses Credentialing Center [ANCC], 2013). While having a Magnet status is difficult to obtain for smaller hospitals, there are other programs out there for rural hospitals such as Texas’ Nurse Friendly program. This program has core concepts similar to the Magnet Recognition Program with the aim of enhancing the practice environment (Meraviglia et al., 2008).

Professionalism is an important notion that recognition programs seek to promote. From the perspective of contingency theory, programs that empower nurses and elevate their ideal of professionalism are shown to help with recruitment and retention (Sanders, 2010). When nurses are allowed to have their voices heard, are allowed to collaborate with other disciplines, and are allowed to make decisions on how they practice, they have more satisfaction in their job (Sanders, 2010). If the nurse feels no satisfaction in his or her work environment, other opportunities start to look better.

Psychological Contract

Another social theory that can explain the nursing shortage in general is the psychological contract theory. This theory is defined by a promise in exchange for something of value (Censullo, 2008). It can be explained by the perception of the employee regarding the “organization’s responsibility and expectations of mutual obligation” (Censullo, 2008, p. E14). When the employee feels the contract has been violated as a result of an action or even a non-action by the employer, then the employee will often see this as a reason to terminate his or her employment (Censullo, 2008).

In rural facilities, we have established that there are nursing shortages. This shortage causes a strain on the nurses working in conditions that leave them with fewer staff, or requiring them to work overtime. Additionally, rural facilities often operate with limited budgets, which can influence yearly pay raises (Censullo, 2008). When the nurse views the non-action of his or her employer not hiring enough staff, or not doling out a pay raise, the nurse can see this as a breach of contract. When the nurse perceives the contract has been broken, then the nurse has the excuse of leaving, or moving on.

The Stakeholders

There are many elements at play with regards to the rural nursing shortage. The health care environment in rural areas has a direct relationship to the lack of nurses. The stakeholders, as mentioned above, are the nurses, the facilities where they are employed, the communities in which they work, nursing schools, both local and national government entities, and anyone that has an interest in the delivery of safe health care.

Nurses

Job satisfaction.

Nurses have their own responsibility when it comes to the nursing shortage. Nurses must remain engaged in the learning process and take some initiative when it comes to their own education. When nurses engage in their learning and apply information to their practice, they feel empowered (McCoy, 2009). When nurses feel empowered they feel valued, and when that happens they find greater satisfaction in their work (Sanders, 2010), and this job satisfaction leads to less turnover (Molanari, Jaiswal, & Hollinger-Forrest, 2011).

From a quality and safety perspective, nurses must strive to keep abreast of evidence based practice. Research has shown that there are many barriers for rural nurses in pursuit of evidence based practice material (O’Lynn et al., 2009). These barriers include being isolated from those that do the research, not having the time to seek it out, not knowing how to locate it, not having the technology to search for it, not having access to journals, and not being adept at interpreting the information once it is found (O’Lynn et al., 2009).

One additional barrier that nurses in rural areas face in regards to finding and implementing evidence based material is that nurses with their baccalaureate degrees are more likely to find and apply evidence based material (Bushy, 2006). This is problematic in rural locations, as most nurses in rural areas only have their two year degree (Skillman, Palazzo, Keepnews, & Hart, 2006). Studies have also shown that rural registered nurse were “more likely to be rewarded less when they had their baccalaureate degree” (Skillman et al., 2006, p. 156). This points to less incentive in furthering his or her education.

Staffing.

The nursing shortage also has a two pronged effect when considering staffing ratios. Firstly, chronic understaffing of nurses, with the resulting higher staffing ratios, leads to increased stress, less job satisfaction, and burnout which in turn causes high turnover for staff (Tourangeau, Thomson, Cummings, & Cranley, 2012). The leftover staff then must deal with the lost peer while management looks to recruit a replacement. To make the situation worse, it has been shown that it takes longer to recruit nurses in rural areas than in urban ones (Molanari et al., 2011).

A second factor on how staffing ratios can worsen the nursing shortage is when management attempts to lessen staff ratios in an effort to ensure quality and safe delivery of care. By decreasing staff ratios, there is then a need for more nurses to take care of the same number of patients (Tourangeau et al., 2012). When there is already a nursing shortage, this can be problematic for the facility.

Aging workforce.

One additional factor that will worsen the nursing shortage in coming years is the age of the current workforce of nurses. According to statistical data, more than fifty percent of registered nurses are at least forty years old and forty percent are older than fifty (Burrows et al., 2012). The expected need for new nurses to fill the shoes of the soon to be retired is more than what are currently enrolled in nursing programs (Burrows et al., 2012). This criteria may not be rural specific, but coupled with the fact that there is already a severe shortage in rural areas, it makes it only worse (Cramer, Duncan, Megel, & Pitkin, 2009).

Facilities

Facilities where rural nurses are employed have also demonstrated a link to the nursing shortage in those areas. Those facilities have a responsibility in making sure nurses have sufficient orientation, have opportunities for professional advancement and educational opportunities, and offer fringe benefits that would help with recruitment and retention, which all can lead to job satisfaction (Teasley et al., 2007). This lack of attention toward nursing staff all leads to high turnover (Tourangeau et al., 2012).

Orientation.

When nurses start out new at a facility, whether it is as a new graduate or just changing departments, it is the responsibility of management to ensure each nurse has a well defined orientation that is adhered to so the nurse can deliver safe care once off orientation. Often times in rural facilities these new nurses are expected to be prepared to work as a generalist, having previous knowledge working with many different types of patients (Molinari & Monserud, 2008). Additionally, because of budgetary restraints, these nurses are often given short orientations, or orientation is interrupted for the nurse to be used to perform tasks in other departments (Molinari & Monserud, 2008).

Professional advancement.

One method health care facilities use to promote job satisfaction is to offer opportunities for professional advancement. More urban facilities are able to offer programs like the Magnet Recognition Program, shared governance, and clinical ladder programs (Manahan Roberge, 2009). In the absence of these types of programs for rural nurses, there is no sense of job satisfaction or even a voice in how nurses practice (Teasley et al., 2007). As mentioned earlier, low job satisfaction impacts nurse retention.

Education.

Education for rural nurses also has a bearing on the nursing shortage. Rural facilities do not often have money in the budget to offer continuing education opportunities such as seminars (McCoy, 2009). Furthermore, if a facility is able to put together a seminar, there may not be enough nurses left over to watch the patients (McCoy, 2009). Facilities also may not be able to afford the access to scholarly journals so evidence based material can be learned and put into practice (McCoy, 2009). All of these reasons influence whether or not a nurse stays in a rural position (McCoy, 2009).

Benefits.

Rural facilities do not have the resources available to offer fringe benefits like their urban counterparts (Manahan Roberge, 2009). Urban facilities are able to offer sign-on bonuses, larger tuition reimbursement packages, day care for children, and education allowances (Manahan Roberge, 2009). By simply not being able to provide these extra items, jobs in rural facilities are not as competitive.

Communities

Communities where rural nurses practice also have a responsibility when it comes to the nursing shortage. One researcher suggests that rural communities need to expose school age children to the possibilities of having a career in nursing so interest can start early (Bushy, 2006). Studies show that nurses that practice in rural areas are likely to grow up in rural communities, and many often stay in the communities where they were raised (Molanari et al., 2011).

For those communities that have culturally diverse populations, there must be an outreach program to bridge the gap between outsider and insider (Crow et al., 2011) One study demonstrated that without a cultural mentor in place, the nurse unfamiliar with the culture often does not connect with the community and leaves his or her post early (Crow et al., 2011). If the community is not involved in helping the nurse adapt, then it is to the communities’ detriment.

Communities must also make the environment attractive for the rural nurse. Obtaining grants to establish clinics, working with state and local governments to expand services in their area, and developing relationships with colleges are all ways communities can attract nurses to the area (Cramer et al., 2009). Communities can also partner with facilities to develop strategies to get nursing more involved with the area so a personal connection can be established because without connectedness, the nurse may feel the added burden of being socially isolated (Bushy, 2006).

Nursing Schools

Nursing schools have historically prepared students to practice in urban facilities, thus the nurse is less prepared to work in a rural area (Teasley et al., 2007). Nursing schools have the responsibility of providing clinical rotations in rural areas for those students expressing interest in working in rural locations (Teasley et al., 2007). The schools need to prepare the students to expect to work as a generalist and prepare them to deal with the wide spectrum of patients (Teasley et al., 2007).

Government

Governments should develop an interest in the rural nursing shortage as they have the power to make change at higher levels. Government agencies have the power to collect facts regarding the shortage, have the ability to enact laws that will promote nursing recruitment and retention, and have the funds to implement programs that influence the shortage (Kirschling, Harvey-McPherson, & Curley, 2008). With respect to funding, governments need to be proactive in funneling money to rural areas, as this is where the greatest need is (Bushy, 2006). Without a greater budget, facilities are not able to compete with urban centers (Bushy, 2006).

Consequences

Recruitment and Retention

Rural health care facilities struggle with finding ways to lure nurses to work in rural areas and once there, keep them there. Rural facilities are chronically under funded and struggle to keep up with the wages and benefits that urban facilities can offer (Tourangeau et al., 2012). It takes up to sixty percent longer to recruit nurses in rural areas (Cramer et al., 2009). This delay in finding staff is detrimental on the existing staff, causing them to have potentially heavier workloads and work extra hours which leads to burnout (Cramer et al., 2009). If the rural nurse decides to leave, this causes further problems for the facility as it has been determined that “the turnover cost per nurse is at least double the nurse’s salary” (Burrows et al., 2012, p. 4). It is a never ending cycle that perpetuates the shortage.

Rural facilities are not often able to increase job satisfaction for nurses through improved work environments. Urban facilities are able to offer programs like the Magnet Recognition Program, and many offer clinical ladder programs that help with professional advancement (Sanders, 2010). When rural facilities are not able to provide programs that empower nurses, job satisfaction suffers, leading to burnout as previously discussed. If these programs are not implemented, then rural facilities will continue to lose their nursing staff to urban areas.

Nursing Schools

Nursing schools are often located in more densely populated areas (Cramer et al., 2009). These schools are adept at preparing the student nurse to function in an urban area, “exposing them to more complex and highly technical aspects of patient care, which is essential for a nurse working in a large urban hospital” (Cramer et al., 2009, p. 149). By not offering clinical opportunities for students who wish to practice in rural areas, and not offering pertinent education that would serve the rural nurse students will continue to experience a level of frustration when going to rural areas to practice (Cramer et al., 2009). This frustration leads to a decrease in job satisfaction, thus leading to burnout as previously described.

Government Involvement

Increased government involvement is able to help alleviate the nursing shortage in rural areas by making education more accessible, more affordable, all while stimulating nursing growth in these areas. The Patient Protection and Affordable Care Act (ACA) has attached with it many programs that will address these issues (Wakefield, 2010). One piece of the ACA is the Nursing Student Loan program that increases the amount of money a nursing student can take out based on earlier programs, while forgiving a larger portion of it based on how many years he or she serves in an underserved area like those found in rural locales (Wakefield, 2010).

Local governments are able to make an impact on the nursing shortage in rural areas by partnering with nursing schools to bring nursing programs to rural areas. One such endeavor happened in a rural community in Nebraska where local government and the community in question approached the University of Nebraska in attempting to bring a nursing school to their rural area. After a coalition was developed, their research showed that a nursing school was feasible in the area so a rural community of nineteen townships could “grow their own nurses” (Cramer et al., 2009, p. 150). The idea being if the local students could go learn in their own communities, they would stay after graduation and be a part of the health care environment (Cramer et al., 2009).

Quality and Safety

American Nurses Association (ANA) Standards of Professional Performance

Quality and safety initiatives are important ways to deliver optimum health care. Now days, patients expect to receive health care in a fashion that is free from error, of the highest quality, and is steeped in safety (Jukkala, Greenwood, Ladner, & Hopkins, 2010). Current initiatives are generated and tested in urban locations, making rural application quite difficult (Jukkala et al., 2010). For rural health care facilities to promote quality and safety, there needs to be relevant rural initiatives to draw from. The following are recommendations that are applicable to rural locations drawing from the American Nurses Association (ANA) Standards of Professional Performance.

Quality of practice.

The rural nursing shortage is not only experienced in hospitals, but is especially felt in long term care facilities. Because of the nature of the work in nursing homes many nurses get discouraged and experience emotional stress, which leads to poor job satisfaction and high turnover rates (Akinci & Krolikowski, 2005). Nurses that work in rural nursing homes have been concerned with the quality of care they can give while being chronically short staffed (Akinci & Krolikowski, 2005).

One way to increase job satisfaction in nursing homes is to focus on quality of practice. Nurses that work in an environment where they have control over nursing practice are shown to have higher job satisfaction as they feel like they are contributing to the success of their workplace (Weston, 2010). As mentioned earlier, nurses with higher satisfaction in their job are less likely to leave their jobs (Sanders, 2010).

The ANA standard number ten focuses on quality of practice and states “the registered nurse contributes to quality nursing practice” (American Nurses Association, 2010, p. 52). One of the competencies of this standard is “developing, implementing, and/or evaluating policies, procedures, and guidelines to improve the quality of practice” (American Nurses Association, 2010, p. 52). An intervention that nurses who work in nursing homes can implement is being more involved in the policies and guidelines that govern their facility. These nurses are the front line workers that have day to day interactions with the residents of these nursing homes. With their intimate knowledge of the flow of the facility, they are in the perfect position to identify ways to improve processes that can be incorporated into the policies and guidelines of the facility. By researching methods to improve processes, formulating new policies, implementing them, and seeing a difference the changes make, these nurses will have a sense of pride in their work. These very personal contributions will lead to an increase in job satisfaction that will enhance the workplace environment.

Leadership.

The ANA standard number twelve is leadership, which states “the registered nurse demonstrates leadership in the professional practice setting and the profession” (American Nurses Association, 2010, p. 55). One of the competencies of this standard states “mentors colleagues for the advancement of nursing practice, the profession, and quality health care” (American Nurses Association, 2010, p. 55). Mentoring is a positive method of promoting leadership that could be implemented in rural hospitals that would increase the job satisfaction while promoting professional advancement for both the mentor and mentee (Crow et al., 2011).

Mentorship is a powerful tool that is used when a more experienced nurse guides a new nurse with learning new skills and offering advisement (Crow et al., 2011). When used in a hospital setting a mentor would help the new nurse learn clinical skills, but more importantly would hone the mentee’s critical thinking skills so the new nurse would be prepared to deliver safe nursing care once on his or her own. The mentor could assist the new nurse in how to locate evidence based research and teach him or her how to apply it, as using evidence based material leads to job satisfaction (Bushy, 2006). In addition, if the new nurse was new to the rural area, the mentor would serve as a bridge to the community so the mentee could develop a sense of belonging (Crow et al., 2011).

Communication.

The ANA standard number eleven is communication, which states “the registered nurse communicates effectively in a variety of formats in all areas of practice” (American Nurses Association, 2010, p. 54). One of the competencies states “assesses her or his own communication skills in encounters with healthcare consumers, families, and colleagues” (American Nurses Association, 2010, p. 54). Effective communication has been shown to improve health outcomes and reflect in higher quality care when explanations are clear and there is a show of support from the health care provider (Street Jr., Makoul, Arora, & Epstein, 2009).

Nurses that work in rural public health settings have a stake in learning how to enhance their communication skills, as they are connecting with the public on a day to day basis. These nurses must be adept at providing education on a variety of health and wellness concerns, where the information they are conveying is often taken home to be followed by clients. An intervention that would meet the communication standard would be for the rural public health nurse to learn effective communication techniques. A class, seminar, or distance learning course would be a number of ways to discover appropriate methods to receive and send information.

Research shows that nurses who participate in self learning that is specific to their job roles find greater satisfaction in their work (Teasley et al., 2007).

Conclusion

The rural nursing shortage is a real crisis that should concern everyone. There are many factors in play that shape why so few nurses choose to practice in rural areas, and why many do not stay.  Health care facilities, nursing schools, local governments, and consumers all share the responsibility to help create a flow of highly trained, capable nurses to rural areas. Without a qualified workforce of nurses to care for hard-working rural dwellers, these residents face uncertainty and certain physical decline.

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