As recession-wary urban hospitals impose hiring freezes, chilling the hearts of job-seekers, are nursing grads warming to the idea of working in rural areas?

Hard data isn't available, but anecdotal evidence suggests rural hospitals receive more résumés these days from nursing grads looking for work after finding large metropolitan job markets tough to crack.

"I was talking with some of our colleagues in the 'difficult-to-recruit' areas and they are experiencing greater interest," Rebecca M. Patton, MSN, RN, CNOR, president of the American Nurses Association, told ADVANCE.

"If new grads are finding it difficult to find work in cities, they might look for work in less urban areas - where more of them are living now than in years past," offered Susan M. Skillman, MS, a researcher who specializes in the demographics of rural healthcare.

Not all experts are convinced it's happening, though.

"It's hard to say," said Nancy Egbert, MPH, RN, senior clinical advisor in the Office of Rural Health Policy, part of the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services. "We mostly hear from rural hospitals that they're having trouble recruiting nurses and data from a few years ago backs that up. Still, there may be rural areas that are attracting nurses unable to find work in the city and, if that's so, it will definitely fill a need."

Rural States Aggressively Looking

Rural America has always needed nurses, to be sure. About 18 percent of the population lives in rural areas, which make up about 80 percent of the land mass of the U.S.

Small physician offices, federally supported community health centers or rural health clinics, and small critical access hospitals with fewer than 25 beds tend to serve the medical needs of rural communities. All these providers emphasize primary care and chronic disease management.

Heavily rural states such as Kansas, Missouri, Nevada and Alaska "are all aggressively looking for nursing grads, as are areas such as the Florida Panhandle, and everywhere in Texas but Dallas and Houston," said Nancy Miko, a clinical recruiter at Saint Mary's Hospital, Waterbury, CT, where acute care nursing positions are scarce, as they are throughout the Northeast.

"For traditional students finishing 2- or 4-year programs, who are not in long-term relationships and not caring for elderly parents, there are tremendous opportunities - but it requires leaving the Northeast for places like North and South Carolina, especially outside the Raleigh/Durham area," said Miko, immediate past president of the Connecticut Association of Healthcare Recruiters. "But it's very challenging to tell someone who grew up in Connecticut, went to school in Boston and wants to stay in New England there are no opportunities there."

Commuting to Cities

If the economic contraction is indeed sending more nurses to rural hospitals, it represents quite a reversal of fortune.

Skillman analyzed data compiled from the National Sample Survey of Registered Nurses (NSSRN) between 1980 and 2004. During that time, more nurses than ever chose to live in rural areas, but the number working in rural areas did not significantly increase.  

"My study found a growing proportion of RNs living in isolated rural areas, but two-thirds of them don't work in those areas. They work in large cities or larger rural areas," said Skillman, a researcher for the Rural Health Research Center at the University of Washington, Seattle. 

"So the challenge is not just attracting nurses to live in rural communities, but figuring out how to make them want to work there, too."  

Skillman's study also found nurses who live in rural areas - even those who commute and work in urban hospitals - still tend to earn less than nurses who both live and work in urban areas. But money alone doesn't explain why rural facilities have traditionally found it harder to attract nurses.

"One thing I suspect is going on, though it's not the whole story, is that it might be enticing for a rural nurse to work three 12-hour shifts at a larger hospital and then have 4 days at home with the family," Skillman said.   

Also, rural nurses "don't have as many opportunities to jump from facility to facility," she added. "So someone who wants a change of scenery, or to work for a different manager, doesn't have as many opportunities as a nurse in an urban area."

Retention Strategies

If rural hospitals are attracting more nurses in these tough times, how will they retain the nurses they've recruited once the economy rights itself and urban facilities resume hiring?

"A lot of it comes down to working conditions, promotion opportunities, opportunities to learn," said Joanne Spetz, PhD, associate professor in the School of Nursing at the University of California, San Francisco. "Rural facilities need to undertake the same strategies if they want to retain nurses that other facilities take. If nurses like their jobs, and feel good about where they work and live, they will stay around."

One facility following that logic is Carle Foundation Hospital, in Urbana, IL. While not small at 315 beds, it serves a large rural area and assists several tiny rural hospitals.  

One of Carle's key retention tools is a professional ladder that offers nurses a structured ascent from novice to expert. Each level advances a nurse's growth as clinician, leader and educator, culminating in level V, occupied by master's-prepared bedside nurses.

"Not everyone wants to be a manager or a supervisor," observed Pamela Bigler, RN, vice president of patient care services. "The ladder recognizes nurses for growing in the profession at the bedside."

Nurses at Carle Foundation Hospital also share in clinical decision-making and have some autonomy in setting their weekly work schedules.

"We do self-staffing, because many nurses are going back to school," explained Mary Beth Voights, MS, RN, APN, trauma services coordinator. "Nurses work three 12-hour shifts but get to choose what days to work them to accommodate their class schedules."

Personality Fit

It's also important for rural hospitals - and nursing grads too - to understand what type of employee takes to rural life.

Rural nursing "tends to attract nurses who prefer to do it all rather than specialize," Voights said. "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."

A certain type of personality likes the rural setting, Egbert offered. "Their patients are their friends and families. That can create problems - but also close relationships," she said. "That's one reason they like it. They feel so committed to that community."

Small hospital nurses "are amazing," Egbert added. "They wear a lot of hats, because there are so few of them. They might deliver babies then go work in the ER. It's definitely harder." 

Lean staffs force an "orientation toward creativity and innovation" that sets rural healthcare apart, Mary Wakefield, PhD, administrator of the HRSA, told graduates of the Vanderbilt School of Nursing http://www.nursing.vanderbilt.edu/ in Nashville, TN, this past June.

"Rural is nimble, efficient," she told them. "Rural practitioners can turn on a dime."

Michael Gibbons is a senior associate editor at ADVANCE.

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