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Insights on Educating the Rural Nursing Workforce, with Jan Probst

Date: February 1, 2022
Duration: 21 minutes

Jan Probst Jan Probst, PhD, Director Emerita at the Rural and Minority Health Research Center, shares insights on the rural nursing workforce, informed by her work on Rural Nursing Workforce: Current Educational Characteristics and Options for Improvement. She shares findings from that study, as well as recent developments impacting the education of the rural nursing workforce.

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Andrew Nelson: Welcome to Exploring Rural Health, a podcast from the Rural Health Information Hub. My name is Andrew Nelson, and in this podcast we'll be talking with a variety of experts about providing rural healthcare, problems they've encountered and ways in which those problems can be solved.

Today, I'm talking to Dr. Janice Probst. She's a professor at the Arnold School of Public Health and a former director of the Rural and Minority Health Research Center. Thank you for being with us today.

Dr. Jan Probst: Delighted to help.

Andrew Nelson: I saw a couple years ago, you worked on a piece called Rural Nursing Workforce: Current Educational Characteristics and Options for Improvement. Now, are there any developments that have taken place since then that have affected the content of that work?

Dr. Jan Probst: Thank you for giving us the opportunity to talk about our work. First, let me point out that our center did three related research projects in nursing, but we did them before COVID hit. So, we kind of have to anymore preface everything with is it before COVID or is it in the midst of the COVID pandemic? So, we cannot be precisely sure that what we saw then is what we will see now.

But what we were interested in looking at with what is the current educational level of nurses across rural and urban areas? What might therefore be needed? And we also surveyed nursing schools to see what they were doing, and we surveyed practicing nurses to see what they said rural people and rural nurses might need. One of the first things that we found out, looking at just playing the data, are that rural nurses are less likely to be bachelor's level trained than they are to be associate degree nurses.

For listeners who might not understand this, to attain an RN you must have at least graduated from a two-year school and have an associate's degree in nursing. Then you can sit for your RN exam and become a registered nurse ready to work in the field. The Institute of Medicine and the American Association of Colleges of Nursing have both recommended that more and more nurses seek and attain the bachelor of science in nursing, feeling that additional courses and instruction might help foster more critical thinking, more leadership ability in nurses. So, there is a general recommendation that more nurses get the bachelor's degree.

Andrew Nelson: Why do you think this type of educational advancement for nurses is important when it comes to meeting the needs of rural populations?

Dr. Jan Probst: Well, that's an interesting question, and the big answer that I'm going to give you that I got from just scanning some of the notes that we got from rural nurses is scope. We had a little section in our questionnaire where he asked, "What guidance would you give for people educating rural nurses, and what do rural nurses need to know?" And the big thing that they consistently said is rural nurses need a broader breadth of clinical knowledge, and pretty much every kind of knowledge than urban nurses. And one of their concerns was that you have to have this broad base of knowledge while you might be practicing in an area where you won't see the rare cases as often as you might in an urban area.

The nurses who are practicing out there recognize this tension between I need to know everything, but I might not see that very challenging, odd thing as often as if I were in a big hospital. It's a difficult balance, and it's one that we have to address for physicians as well as nurses. The idea of making sure that you keep your skill set up over a broad variety of topics, which had a number of our nurses recommending that if you're in rural, be sure you keep up with your continuing education, which of course in rural may be harder to get. So, life goes in a circle.

Andrew Nelson: Yeah, I suppose in a more urban environment, as long as a hospital had somebody or a couple people that knew how to handle a given health situation, then they could just sort of be diverted to them. Whereas a rural nurse might be the only person that they have direct access to. They have to be able to cover all the possibilities. What are schools doing right now to help some of these nurses overcome barriers?

Dr. Jan Probst: When we surveyed schools of nursing, we found that not all of them are actually recruiting rural students, which makes sense because if you're located in downtown New York or downtown Seattle, that's probably not your priority. But we did find that among those RN to BSN programs, to follow that recommendation that nurses have a higher level of education, that about just under two out of every five, or 38%, said they were really trying to target rural students with their recruitment efforts, which is good because we do want people reaching out.

These schools did not say that there was any problem with their rural applicants. A lot of them, two thirds of them, said that they admitted all their rural applicants. So, the people who are applying from rural areas to get additional training, to go from an ADN level of nursing education to a BSN, are certainly being accepted by the institutions. But they do feel that there are some problems that students face.

A lot of them, of course, are going to say, as you're going to say everywhere, family obligations. If you're talking about recruiting nurses who are already in practice and trying to help them get their educational needs, if they've got kids, and certainly when I got my doctoral degree I had kids, you have to balance that. And that can really be a struggle when you're working full time and you have kids and you're trying to improve your education. But after that, which we really can't fix for people, cost of tuition was mentioned by over half of new nursing schools as a barrier that their students face, which sort of ties into, related to that, there may not be tuition reimbursement by your employer. So, there's a problem and a solution, if we could get more people to adopt that solution, more employers to support their nurses in getting additional training.

But really it was less the distance that they must travel, because so many schools do offer online options, but they did note that there are barriers for online training for nurses as well. They do note that for students, poor internet connectivity, particularly in rural areas, can be a problem. We know that this is an issue. I would have to double check our studies to get precise percentages, but a certain proportion of rural residents, certainly back in 2019 when we were doing these surveys, simply didn't have the high quality of internet access that you need for direct communication, interacting online education. We are hoping that over time that this may have improved, and I would love to do this survey again just to find out what's going on now.

Andrew Nelson: Have you found that a hybrid delivery system for educating rural nurses can kind of help to offset having to rely completely on internet access?

Dr. Jan Probst: Okay, with regard to how is the best method to offer courses, when we did our survey, which you have to know is pre COVID and pre all of us learning to use Zoom for a thousand things, more than half of programs, just a squinch over 50% said they were online only. And a little under 50%, or 45%, said that they offered a hybrid. Intuitively we think of hybrid where some are online and some are in person would be best, but it's hard to tell.

I think the fact that people may have really focused on either only online or only hybrid pre COVID may be different now. One of the things that we looked at though, that I personally think offers a big vehicle for expansion, and that more of the schools that said they were targeting rural students use is collaborating with community colleges so that if you have your online and your hybrid, if the students can do it in a community college that is in or close to their community, that would seem to offer a lot of advantages in terms of overcoming the family work balance that they have to maintain as nurses to get this education.

My recommendations as an educator and listening to rural learners is let's get a mixture. Let's get everything we can put on our plate out there. We can do online courses that also could be taking place in the live classroom, although teachers also complain about that. There's a lot that I think we have learned that we can do through the COVID pandemic, through remote communication that we didn't know we could do before.

Andrew Nelson: How would you say that rural clinical experiences can be important to developing needed skills, and are these types of placements often available in RN to BSN programs?

Dr. Jan Probst: Interesting that you should mention that because one of the biggest problems people have, and one of their biggest needs, is getting clinical placements when they're doing their training. That is an ongoing challenge. And the schools that focus on rural learners do try a little bit to get more of those clinical sites. That I think is some of the things that partnering with locals, like the community colleges that face those same educational needs, might be advantageous.

Some nurses suggested that everybody should practice for a year in a big urban hospital before they move to a rural setting because they should have as much breadth as possible before they got there. Okay, clearly that isn't going to work for nurses who are already in the rural setting and trying to increase their educational background and improve their skill set.

Andrew Nelson: As nurses are getting ready to enter practice, they have to think about where they're going to be located. Is there a difference between nurses preparing for a rural or urban environment?

Dr. Jan Probst: Great question. Actually, there is. The differences aren't large, but they are still present, and it's useful to keep them in mind. Across all nurses, looking at everybody, the great majority of nurses practice in hospitals. But that majority is a little bit bigger, 65%, than rural, where it's only 59%. The next biggest thing after hospitals is skilled nursing facilities, and rural nurses are more likely to practice in those, 13%, than are urban nurses, 8%.

When you think about the rural landscape where a lot of counties won't have a hospital but will have a skilled nursing facility, that sort of explains why that is the case. When you think about it, the patients in skilled nursing facilities may be at a lower level of acuity than patients in a hospital, but that can change rapidly. That's why you need that, the ability for nurses to have critical thinking and to be able to judge what to do with this patient. Those patterns of greater involvement in skilled nursing facilities then is the case in urban, is present for both BSN prepared nurses who are already out in rural areas, and very, very particularly for associate degree prepared nurses out in rural.

One might a argue that nurses, therefore, who are going to practice in rural, have to know a little bit more about rehab and perhaps about geriatric medicine and perhaps about treating persons who are suffering from various forms of dementia or other bits of cognitive impairment associating with aging than are nurses who are practicing in urban areas. And of course, the rest of nurses are all the places you would expect, physicians' offices, outpatient care centers, home health, and just sort of other which includes public health on a lot of other places that they might be working.

Andrew Nelson: Sure. What are some things nursing schools can do to help rural RN to BSN nursing students succeed?

Dr. Jan Probst: Thinking of what schools can do to help their students succeed is challenging. Certainly, one thing that some schools say that they were doing was beginning the education when they start to bring students in with an orientation to online learning. Nurses who completed their education in the traditional pattern, we go to high school, then we go to college and then we graduate, get an RN and move on. People who did that 10, 15 years ago may not have had to have done any of it online. One of the things that schools did note in their responses to our survey is that they find that midlife learners may not have these skills, and it's a great idea to start out by walking them through that before how you're going to get your education so that it has to precede the content of your education. So, doing that is certainly something that they can help with.

I would also suggest that they could do a little bit more recruiting using, say, some of the community colleges as pipelines perhaps, while the person finishes their degree there, and maybe perhaps starts working in their rural community, but still is hooked up to the larger school of nursing where they can get the additional training they need to improve their skills, move themselves on. Because realistically for the nurses themselves, bachelors trained nurses generally get a salary bump compared to ADN nurses, and we all like salary bumps, especially now.

Andrew Nelson: Yeah, this is kind of a similar question, but looking at rural healthcare facilities instead of nursing schools, what are some things you think that rural healthcare facilities might be able to do to make the RN to BSN pathway attractive?

Dr. Jan Probst: That's very interesting. I think where you work has a lot of influence on whether you decide that it is important and helpful for you to seek further education. Basically, the biggest thing that companies can do to support their employees getting more education is provide tuition reimbursement, whether it's full or partial. Obviously the more, the better. I worked for a company early in my career that offered tuition reimbursement, and we had several employees who basically started almost out of high school, certainly it seemed, and who worked on to get their degree. Providing tuition support indicates that you value advancement in education and that you want to do that.

Obviously, this would have to be to tied into salary structures, to then say, "When you hit this educational milestone, we will increase your salary." We will make this burden easier by picking up part of the cost and we will reward you for it, are two sides of the coin.

A third side of a coin, which of course coins don't really have three sides, is allowing flexibility in hours so that the person who might need to take a course in the middle of the day can restructure themselves. I'm going to put that burden back on the educators themselves. I think we need a good mix of courses that are offered during the day and courses that are offered in the evening. I'm afraid in my own department, one of the lone proponents of this, it never bothered me even though I had kids at home because I did have a husband who could handle them, it never bothered me to work in the evening to teach because I knew that many of our students who, in my case, teaching in a school of public health, were local health department workers getting their masters in public health, the logical step for them. Evening courses are so helpful for people who work on a regular schedule.

At the same time, nurses have to work evening and graveyard shifts. I think colleges need to know the work schedules of their students who are attempting to advance their degrees and employers need to be able, when possible, to offer flexibility. And again, all of this is in a statement of pre COVID, because from everything I can understand right now, just keeping the hospital staffed, the outpatient clinic staffed, keeping things staffed is difficult right now because there are so many challenges due to increased patient loads combined with practitioners themselves becoming ill and having to drop out of the workforce.

Andrew Nelson: Sure, yeah. Aside from COVID implications on the rural nursing workforce supply, are there any other outstanding questions that you'd like to investigate going forward with your research center?

Dr. Jan Probst: Well, this is not so much a research question, but something that I know is happening that I think we should be tracking and evaluating. Part of the infrastructure bill that was recently passed is improving rural internet. I am totally, totally curious to see the degree to which that will actually succeed. I expect this doesn't happen in 20 minutes, that it's going to take a while to build things out and offer supports in rural communities and figure out the price structures that are going to make these things available to everybody.

But if we're talking about nurses who want to further their education, let's assume that price is not going to be an issue. Three years from now, are we going to have more online education? Are we going to have more hybrid education? How are we going to handle post COVID? The nurses who have demand for clinical training. Certainly, COVID has totally squished the degree to which we can take student learners to actual healthcare institutions. As someone who works in an institution that offers masters and doctoral training, I was, "Wait. This is where we take them to visit a rural hospital." Nope. No, it's COVID. We're not going anywhere.

I think COVID has affected education for healthcare professionals, for health administration professionals. I think we need to do some sort of assessment of how badly was our educational program hit. Once we've gotten all the patients taken care of and are in the look back machine, how has it affected what we want to do in the future? Those are important questions I would like to see.

Right now, we're in the middle of it. We can't answer those questions. We're still trying to get COVID under control, and there is no indication that it truly is. But I remain optimistic, since in public health you have to be optimistic. We will get COVID under control. We will get our hospitals and healthcare institutions and educational institutions back into some sort of real time educational mission that does not have to worry about pandemic communicable disease. What will things look like then? And what will the implications be for rural? I am very concerned that the current funding crises may be affecting rural hospitals and rural healthcare, more than we know. It will be curious to see what emerges.

Andrew Nelson: You've been listening to Exploring Rural Health, a podcast from RHIhub. Today, we spoke to Dr. Jan Probst, professor at the Arnold School of Public Health and former director of the Rural and Minority Health Research Center. Look in our show notes to learn more about her work, and visit for all things pertaining to rural health. Join us next time as we begin a three-part series on rural transportation here on Exploring Rural Health.