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
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
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
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
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
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,
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
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 ruralhealthinfo.org 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