Education and Training of the Rural Healthcare Workforce
Maintaining healthy rural communities depends on proper preparation and supply of a rural health workforce, which includes professionals living and working in rural communities and distant providers who provide services or support through telehealth and referral services. This involves ensuring that physicians, nurses, dentists, and other healthcare professionals are well-educated, well-trained, and have had experiences that expose them to and prepare them for rural practice and supporting health care services in a rural context.
Strategies, programs, and activities used to educate and train the rural health workforce may include:
Grow-Your-Own and Career Ladder Programs
- Programs like job shadowing, career fairs, and scrubs camps, that introduce rural students to health careers
- Healthcare facility programs that help employees advance their education and careers, including apprenticeships
Education & Training Provided in Rural Areas
- Nursing and allied health education at rural community colleges
- Rural rotations or curricula, including rural interprofessional education experiences
- Residency programs and fellowships specifically designed to train physicians and nurse practitioners for rural practice
- Continuing and professional educational opportunities for rural health professionals
Technology to Educate the Rural Health Workforce
- Distance learning
- Telehealth applications for learning
Investing in rural healthcare education can facilitate recruitment and retention efforts in rural areas, reducing workforce shortages and increasing diversity.
Frequently Asked Questions:
- How can grow-your-own programs improve the future health workforce available in rural areas?
- Where can I find information on Medical School Rural Tracks and Rural Training Track Residency Programs?
- Do rural health rotations and curricula increase the likelihood that students will practice in rural areas?
- What are Area Health Education Centers (AHECs)? How do they help to prepare the rural healthcare workforce?
- Why is interprofessional education important for future rural healthcare professionals?
- How are online and telehealth training being used to prepare the rural healthcare workforce?
- How is simulation technology used to educate rural healthcare providers?
- What role can community colleges play in healthcare workforce education in rural areas?
- What admissions criteria can health professions programs consider to identify students likely to go on to practice in a rural community?
- What cultural competency skills do rural healthcare providers need and what types of training are available?
How can grow-your-own programs improve the future health workforce available in rural areas?
Grow-your-own programs help to address the shortage of healthcare workers in rural areas. They focus on encouraging individuals to consider choosing healthcare careers, cultivating their interest, and helping them develop skills that they can use professionally in their home communities. This approach recognizes and builds on the idea that health professionals are more likely to consider serving in the community in which they were raised. It does not provide healthcare workers who will enter the labor force immediately. Instead, it is a long-term strategy that moves people into the health workforce pipeline and enables rural communities to more effectively address their future healthcare workforce needs.
Parental involvement can be key in sparking young people’s interest in healthcare careers. Regionally, targeted admissions processes into healthcare professions training can also be a key factor in recruiting and training graduates more likely to return to their home communities or similar rural areas.
Career awareness and exploration programs provide an effective way for community organizations to work together, partner with healthcare facilities and schools, and expose students to careers in rural healthcare. For example, scrubs camps provide students the opportunity to meet and interact with a variety of healthcare professionals and engage in healthcare-related activities. These camps increase interest, awareness, and understanding of health careers available in rural areas among elementary through high school students.
Other career awareness and exploration activities that healthcare facilities or schools might undertake include:
- Hosting healthcare career fairs
- Inviting healthcare workers to schools, to speak about their careers
- Providing opportunities for students to shadow healthcare professionals
- Ensuring that teachers and school counselors are aware of requirements for entering health professions schools, so that they can make informed suggestions about which courses and activities will make students strong candidates for admission
Career ladder programs are sponsored by healthcare facilities to help employees advance their education by developing higher-level skills. These programs tend to increase employee satisfaction, which leads to higher retention rates. Programs may include:
- One-on-one career counseling and mentorship
- Tuition reimbursement or assistance with other educational expenses
- Paid time off to pursue training
- Onsite training and education opportunities, including apprenticeships
Where can I find information on Medical School Rural Tracks and Rural Training Track Residency Programs?
Medical School Rural Track (RT) Programs
Many medical schools offer programs that provide rural training experiences to students who are considering practice in rural areas. Rural tracks (also called programs, pathways, concentrations, or other terms) give students exposure to the broad scope of practice rural physicians experience. This can fuel students’ interest in residency and a career in a rural area. For other students, it helps them realize that they are better suited to an urban environment, which is important to know before committing to rural practice.
- University of Missouri School of Medicine’s Rural Track Elective Program
- Targeted Rural Underserved Track (TRUST) Program
- Rural Opportunities in Medical Education (ROME)
- Rural Physician Associate Program (RPAP)
A 2013 study of the 35 existing and planned medical school rural tracks showed that the number of students participating in a given program ranges from 4-60, typically 5-10% of a medical school class. Medical School Rural Tracks in the US, a policy brief on the study findings, also identified the following key points about rural tracks:
- Selection criteria for the programs often include rural background, a commitment to serve rural areas, and a desire to enter a primary care discipline
- Many programs offer scholarships for rural track participants
- Most rural tracks rely on funding from sources other than their medical school
- The annual cost of running a rural track for 15-25 students is $350,000-$600,000
- Approximately 44% of rural track graduates reported entering rural practice
Rural training tracks (RTTs) and other residency program models involving time spent in rural areas provide graduate medical education to prepare resident physicians for careers in rural family medicine. Programs also exist for critically relevant rural specialties, such as general surgery, internal medicine, pediatrics, and obstetrics. Shortages in the rural primary care workforce are a serious concern that residencies with a rural focus attempt to address.
Recently, the Health Resources and Services Administration (HRSA) has funded the formation of rurally located residency programs under the Rural Residency Planning and Development Program, with a supporting website, RuralGME.org, offering technical assistance to forming new programs.
Family Medicine Rural Training Track Residencies: 2008-2015 Graduate Outcomes reports that over 35% of graduates of RTT residency programs were practicing in rural areas during the 7 years after graduation, which is about twice the percentage of former family medicine residents overall.
Other models of rural residency training include:
- Rurally located residency programs
- Urban-located programs with a rurally located continuity clinical site
- Urban-located programs with rural focus
Some rural residency programs offer opportunities for students to complete residencies in community clinics and community hospitals. The Teaching Health Centers model, begun in 2011, allows residents to receive clinical training in centers that provide community-based ambulatory care. In this way, they can learn to provide care for patients in underserved areas.
In addition to family medicine residencies, there are some rurally-oriented general surgery and OB/GYN residency programs. The American College of Surgeons maintains a list of rural surgery programs. The University of Wisconsin-Madison's Department of Obstetrics and Gynecology was the first OB/GYN program in the country to offer a separate rural residency track.
For recommended curriculum guidelines, see the National Rural Health Association Policy Brief, Graduate Medical Education for Rural Practice.
For more information about Rural Training Tracks, visit:
- RTT Collaborative – A national cooperative of rural education and residency programs.
- RuralGME.org – An organization bringing together experts in all aspects of rural graduate medical education.
Do rural health rotations and curricula increase the likelihood that students will practice in rural areas?
Comprehensive Medical School Rural Programs Produce Rural Family Physicians, an article in American Family Physician, examined three comprehensive medical school rural tracks, which produced six times the national average for graduates practicing in rural areas. The Impact of Rural Training Experiences on Medical Students: A Critical Review, published in Academic Medicine, reports on a review study of 72 studies related to rural training experiences. The authors found that:
…most studies revealed that student experiences in a rural setting predicted future employment. In general, medical students completing rural rotations were three times more likely to practice in a rural community compared with the national average…Students in self-report studies felt that their skills significantly increased in areas such as chronic disease management and ability to handle acute problems, with the largest gain in understanding health systems and the community during their rotation in a rural primary care clinic.
Authors of Recruiting Rural Health
Providers Today: A Systematic Review of Training Program Success and Determinants of Geographic Choices
examined 55 studies exploring the impact of medical training programs and found that
Growing up in a rural
community is a key determinant and is consistently associated with choosing rural practice. An
AcademyHealth review article, What Are Effective
Approaches For Recruiting and Retaining Rural Primary Care Health Professionals?, evaluated
various strategies and found an association between exposure to rural areas and medical students'
subsequent decision to practice in these areas. The authors of this article caution, however, that the studies
they examined did not control for the possibility that the students who chose rural medical training experiences
were already inclined toward rural practice.
The 2011 Academic Emergency Medicine article Availability and Potential Effect of Rural Rotations in Emergency Medicine Residency Programs describes the types of rural rotations in emergency medicine residency programs and the correlation with rural practice after graduation. Emergency medicine residency graduates were more likely to select a rural job if rural rotations were required.
The WWAMI Rural Health Research Center publication Graduates of Rural-centric Family Medicine Residencies: Determinants of Rural and Urban Practice examines the reasons physicians trained in residencies that required at least eight weeks of rural training selected rural or urban practices. Reasons for choosing rural practice include:
- Positive perceptions of their rural residency training experiences
- Community amenities
- Rural experience prior to medical school
- Being prepared for rural living
- Partner/spouse from a rural area
- Obligations or incentives to work in underserved communities
Rural rotations are also available for other health professions, such as pharmacy, dentistry, advanced practice nursing, and the physician assistant profession. For example, students in West Virginia University's School of Pharmacy must complete a 5-week-long Advanced Pharmacy Practice Experiences (APPE) rotation in a rural areas of West Virginia, and dentistry students must provide several weeks of supervised patient care through the West Virginia Institute for Community and Rural Health.
Other examples of successful rural rotations that prepare students for rural practice include:
- Oregon Health & Science University (OHSU) Rural Surgery Training
- Wisconsin Collaborative for Rural Graduate Medical Education
- University of Washington School of Dentistry: Regional Initiatives in Dental Education (RIDE) Program
- The Colorado Center for Nursing Excellence: Rural and Underserved APRN Project
The RTT Collaborative offers a free tool for determining community capacity for physician residency education. See TREES (Training and Rural health professions Education that is community Engaged and Sustainable).
What are Area Health Education Centers (AHECs)? How do they help to prepare the rural healthcare workforce?
Area Health Education Centers strengthen the supply and distribution of healthcare professionals in rural and underserved areas, focusing on primary and preventive care. AHECs act as liaisons between communities and academic institutions and assist in arranging training opportunities for health professions students, tailoring their programs and activities to the needs of their region.
AHECs help prepare students for rural healthcare through activities such as:
- Recruiting and training minority students and those from disadvantaged backgrounds
- Placing students in community-based clinical practices settings, focusing on primary care
- Improving quality of care by promoting interprofessional education and collaboration
- Facilitating programs and continuing education resources for health professionals in rural and underserved areas
- Conducting pipeline activities to expose pre-college students to health careers
The National AHEC Organization provides a directory of AHECs. According to its website as of 2019, there are at least 46 AHEC programs with more than 261 centers operating throughout the United States, working collaboratively with approximately 600 nursing and allied health schools and 120 medical schools.
The AHEC Scholars program is open to students enrolled in a wide range of healthcare and pre-healthcare certificate or degree programs. The instruction supplements students’ existing training programs, and must take place in rural or underserved areas. Each cohort lasts two years and ends in completion of a certificate or a degree.
AHECs are funded through the HRSA Bureau of Health Workforce. They also use other funding streams to match their federal funds and operate additional programs. Successful programs include:
- Rural Experiences for Health Professions Students (REHPS), based in the Yankton Rural Area Health Education Center, raises awareness for healthcare needs in underserved areas of South Dakota through placement of health professions students in rural or frontier areas of the state.
- The Naloxone Education Empowerment Distribution Program, organized by the San Luis Valley Area Health Education Center, worked to train and certify healthcare workers and community members to administer naloxone. This was a one-year program that ended in September 2016.
- Project PROMISE (Providing Rural Opportunities in Medicine through Inspiring Service and Education), is an educational and experiential pipeline program based in Spruce Pine, North Carolina. This program provides high school seniors with medical academic training, mentor relationships, and experience in rural North Carolina medical facilities.
- The FORWARD NM (Frontier and Rural Workforce Development New Mexico) Pathways to Health Careers program has initiated grow-your-own activities to support comprehensive workforce pipeline programs for middle and high school students, undergraduates, medical students, graduate students, and resident physicians.
- The MU AHEC (University of Missouri Area Health Education Center) Summer Community Program provides opportunities for second-year medical students to work under the direction of rural community-based physicians for 4 to 8 weeks.
Why is interprofessional education important for future rural healthcare professionals?
The goal of interprofessional education (IPE) is to prepare students to practice team-based care after graduation, which is important to ensure patient-centered, coordinated care in rural areas, particularly if all members of the care team are not in the same location.
Rural student IPE experiences often involve a rotation in a rural underserved area to learn how different professions work together. Students interact with healthcare professionals, learning about building relationships and teamwork.
For further information on the impact of rural IPE programs, see:
- Impact of a Rural Interprofessional Experience in Rural Communities on Medical and Pharmacy Students, Family Medicine, 43(8), October 2011
- Learning By Doing: The MD-PA Interprofessional Education Rural Rotation, Rural and Remote Health, 17(1), March 2017
- Rural Experiences for Health Professions Students – A 4-week summer program placing health professions students in rural South Dakota communities
- Right Side Up Falls Prevention – A program to address prevention and management of falls and risk of falls, through in-home assessments by interdisciplinary healthcare professionals and students
How are online and telehealth training being used to prepare the rural healthcare workforce?
Rural healthcare workers are often reluctant to leave their homes or place of employment for training and education due to travel challenges, coverage in staffing, and costs. Online and telehealth training programs can provide accessible training for current and future healthcare professionals. These programs may provide degree programs, continuing education classes, training in cultural competency skills, and leadership training.
The Rural Monitor article Education at a Distance: Virtual Classrooms Bring Healthcare Classes to Rural Areas highlights distance and hybrid programs for occupational therapy, physician assistant programs, and nursing. These allow rural students to earn their degrees while living and working in their home communities.
RHIhub's Rural Health Models and Innovations features the following successful online training programs:
Learning Exchange Reverse Demonstration (LERD) Model
Located at the University of Missouri-Kansas City School of Nursing and Health Studies, the Rural Nurse Initiative RN-BSN program helps rural nurses continue their education.
EMS Live @ Nite
Provides monthly training to rural EMS providers throughout the northwestern United States.
Project ECHO® (Extension for
Community Healthcare Outcomes)
Developed to provide increased capacity for chronic disease management. The model uses videoconferencing to connect primary care providers with specialists who can assist with patient treatment and increase the knowledge base of participants.
How is simulation technology used to educate rural healthcare providers?
Various forms of simulation have been a part of healthcare education for many years, including volunteers role-playing patients, practice suture pads, and anatomical replicas. However, improvements in technology have advanced the capabilities of the simulation tools available to students.
Simulation Technologies in Higher Education: Uses, Trends, and Implications, a 2010 publication from EDUCAUSE, reports that simulation technology is most often used to practice low-frequency events that require high acuity, such as emergency procedures and irreversible procedures such as surgery. Since rural healthcare professionals typically see fewer high acuity events, simulation is especially useful in rural areas.
The 2013 article Integrating QSEN and Technology to Address Rural Health Care: Initial Outcomes presents results of a project intended to promote six core competencies in the Quality and Safety Education for Nurses initiative, through technology-focused simulation exercises.
Two methods of simulation technology are discussed in Medical Simulation Education: Results of an AAMC Survey, a 2011 study by the Association of American Medical Colleges (AAMC). These are:
- Mannequin Simulation – The AAMC study indicates that the most common type of simulation equipment is the full-scale computerized mannequin, described as a life-sized robot that mimics various functions of the human body, including respiration, cardiac rhythms, and pulsation.
- Screen-based Virtual Reality – The AAMC study defines screen-based simulation as a program, exclusively computer-based, that allows learners to interview, examine, diagnose, and treat patients in realistic clinical scenarios. Examples include virtual patients, virtual environments, or physiologic simulations.
Examples of simulation technology used in rural areas include:
Simulation in Motion – Nebraska (SIM-NE)
Uses four custom simulation vehicles with high-quality patient simulators, to help train rural emergency medical service providers.
Penn State Learning Center
Video describing activities at a training center for rural healthcare professionals
of Missouri Health System School of Medicine: Mobile Sim
Provides interactive training in rural areas of Missouri through the Mobile Sim clinical simulation service
Institute for Nursing & Health Care: Rural North Area Simulation Collaborative
Provides training from Sacramento to the Oregon border and from the Sierra Nevada to the Pacific Ocean
Rural Northern California Clinical Simulation Center
Includes numerous simulators, mock patient rooms, and state-of-the-art education tools for rural healthcare professionals
Sharpen Skills of Rural Practitioners
Highlights South Dakota Simulation in Motion, Society for Simulation in Healthcare, Shelden Clinical Simulation Center, and Peter M. Winter Institute for Simulation, Education, and Research
What role can community colleges play in healthcare workforce education in rural areas?
Community colleges play an important role in educating students who plan to work in healthcare, particularly people in nursing and allied health fields. These schools offer degrees and certifications in a variety of healthcare occupations, including programs for:
- Medical assistants
- Respiratory therapists
- Health information/medical records technicians
- Dental assistants and hygienists
- Surgical technologists
- Physical therapist assistants
Career counselors at community colleges should keep abreast of employment trends, including the needs of local healthcare employers, and certification requirements for healthcare professions, so that they can guide students toward courses and activities that will be most beneficial.
Community colleges strive to provide educational opportunities close to rural communities. In the 2012 policy brief The Contributions of Community Colleges to the Education of Allied Health Professionals in Rural Areas of the United States, the WWAMI Rural Health Research Center studied the geographic relationships between community college programs for 18 allied health occupations, rural populations, and healthcare facilities that hire these professionals. The researchers found that:
- 99% of urban residents lived within a one-hour drive to a community college offering allied health coursework, compared with 73% of the rural population.
- Access varied by region, with 58% of the rural population in the West living within a 60-minute drive compared with 90% in the Northeast.
- Some programs had a higher percentage of rural students within a 60-minute drive, such as Medical/Clinical Assistants, Emergency Medical Technicians/Paramedics, and Surgical Technologists.
According to a joint statement issued by the American Association of Community Colleges and the Association of Community College Trustees in 2017, associate degree programs play an important part in the training of nurses who work in rural areas, noting that 39% of RNs working in rural and urban healthcare facilities earned their degrees through community colleges.
Rural Health Information Technology Workforce Curriculum Resources offers a complete inventory of curriculum resources, including course descriptions and training materials, developed by the Federal Office of Rural Health Policy's Rural Health IT Workforce Program grantees. Many of the training programs were created in rural community college settings. Community colleges and vocational or technical institutions that are developing similar programs are encouraged to use and build on these curriculum resources.
What admissions criteria can health professions programs consider to identify students likely to go on to practice in a rural community?
The shortage of health professionals in rural America can at least partially be addressed through educational programs. To produce students who are likely to practice in rural areas, schools must consider factors that are good indicators of future rural practice. This might be at odds with the traditional tendency of educational programs to recruit the students deemed most elite by traditional criteria.
For instance, medical school admissions committees in the United States have historically given preference to the “best of the best” applicants in terms of academics — those with the highest grades and Medical College Admissions Test (MCAT) scores as well as a well-rounded background in extracurricular activities, and volunteer or work experience. Applicants meeting these criteria are likely to be from a background of high socioeconomic status. In 2018, 66.5% of students entering medical school in the United States had parental incomes of over $100,000, according to the 2018 AAMC Matriculating Student Questionnaire. Applicants from urban areas typically have more opportunities to pursue activities that will make them seem “well-rounded” to admissions committee members.
Medical school admissions committees that include faculty members who themselves have rural backgrounds may be more inclined to look favorably on rural applicants with characteristics such as resilience and work ethic.
By using the traditional admissions criteria, medical schools can produce excellent physicians. However, if those doctors are not inclined to practice in rural communities, maldistribution occurs which ultimately results in poorer healthcare access for rural Americans.
Characteristics important for rural practice are addressed in Competence Revisited in a Rural Context and include:
- Living with scarcity and limits
- Reflective practice
In its 2007 Eighteenth Report: New Paradigms for Physician Training for Improving Access to Health Care, the Council on Graduate Medical Education (COGME), urged medical schools to admit more students from underserved areas, stating:
There must be an incentive for medical schools to admit minority students as well as students from underserved urban and rural areas. This would increase the likelihood that graduates return home to practice medicine. The admissions practices of many medical schools raise the thorny question of whether admissions committees cause and perpetuate the physician maldistribution problem.
The COGME report went on to suggest that states should provide incentives for medical schools to develop special admissions tracks for rural students, as well as those from other backgrounds that might qualify them as disadvantaged. A 2016 article from Inside Higher Ed notes that this advice may have been followed: As of that writing, 84 percent of U.S. medical schools either already had or were planning to implement policies to recruit students who intend to practice in underserved areas.
The Rural and Remote Health article Medical Student Characteristics Predictive of Intent for Rural Practice notes that factors associated with intention to practice medicine in a rural area including being raised in a rural community and having a significant other who has lived in a rural area.
Intended specialty area is another indicator that can be used to predict future rural practice. Patching the Rural Workforce Pipeline – Why Don't We Do More? indicates that applicants interested in family medicine are more likely to enter rural practice, particularly when they have a rural background or interest.
Some medical schools with a rural mission or a rural track do use criteria related to rural interest. Medical School Rural Tracks in the US identifies characteristics sought for rural track applicants:
- Rural interest or background (39 programs cited)
- Rural commitment (23 programs)
- Community involvement (20 programs)
- Primary care commitment (18 programs)
- Character (18 programs)
- Resident of state/area (15 programs)
Dental school admissions committees have also come to recognize the significance of rural background as a predictor of rural practice. A 2012 article noted that dentists who came from rural areas were about 6 times more likely to practice in rural communities than their urban counterparts, based on 30 years of data from a Midwestern dental school. The 2016 article Do Dentists from Rural Areas Practice in Rural Areas? notes that some dental schools, including those at East Carolina University and Virginia Commonwealth University, have put priority on recruiting students from rural areas in an effort to address shortages in underserved communities.
Some schools of pharmacy also offer concentrations geared toward students who come from rural areas or would like to practice in a rural community. Examples include the Rural Pharmacy Education Program (RPHARM) at the University of Illinois-Chicago College of Pharmacy and the Rural Health Professions Program at the University of Arizona College of Pharmacy.
What cultural competency skills do rural healthcare providers need and what types of training are available?
As the rural population of the United States becomes more diverse, healthcare providers are serving more patients with backgrounds, beliefs, and language skills that are different from their own. According to Cultural Competence Education for Students in Medicine and Public Health, cultural competencies fall into three domain areas:
- Knowledge (Cognitive Competencies) – Understanding cultural diversity and the influence of culture on health outcomes
- Skills (Practice Competencies) – Integrating cultural perspectives into treatment/interventions, communicating in a culturally competent manner with patients, and incorporating culture as a key component of patient history
- Attitudes (Values/Beliefs Competencies) – Appreciating how cultural competence contributes to the practice of medicine, assessing the impact of one’s own culture on care and service, and realizing that cultural competence involves lifelong learning
Several agencies and organizations provide resources and/or training to implement cultural competence within an organization.
Center for Cultural Competence (NCCC)
Located at Georgetown University. Contributes a variety of services for health and mental health programs wishing to design, implement, and evaluate culturally and linguistically competent service delivery systems. Services include a resource database, tools for self-assessment, technical assistance, consultation and training events.
CDC's Office of Minority Health & Health Equity
Develops health policies and programs to eliminate health disparities and serves as a national resource and referral service on minority health issues. Offers student opportunities in public health.
Cross Cultural Health Care Program (CCHCP)
A nonprofit training and consulting organization dedicated to promoting culturally and linguistically appropriate healthcare. Features a medical interpreter training program and offers assessment tools, resource lists, and bilingual medical glossaries in 24 languages.
Think Cultural Health
Provides free online and accredited cultural competence continuing education programs for physicians, pharmacists, nurses, and social workers. A product of the Office of Minority Health, U.S. Department of Health & Human Services.
Provides free online training in cultural competency skills including health literacy and Limited English Proficiency. This training module can be taken for credit or non-credit and is appropriate for healthcare professionals.
Last Reviewed: 9/30/2019