Rural nursing shortages leave critical access hospitals in tough spots

DAVENPORT, Wash. – Chris Harper enjoys her four-minute commute to Lincoln Hospital so much that she’s been doing it for nearly 35 years.

While it might be tempting to assume rural medicine is slow, Harper describes her career as a registered nurse in Davenport as one marked by variety and movement across several units, all in a day’s work.

“Every day is different; you never know what you are going to do,” said Harper, who grew up in Ritzville. “Sunday was the last day I worked. There were four patients, and I thought a couple of them would be leaving, so I thought I would come in today and it would be a quieter day. And we have one empty bed, so it’s not a quieter day, it’s a much busier day.”

This is the reality of life at a 25-bed critical-access hospital: The ebbs and flows of patients demand more from its staff, at times, but that varied work can be rewarding and broadening for clinical experiences.

Harper recalls days she has worked in the emergency room, on the transitional care unit, in surgery – and then done it all over again, depending on who walks through the door.

While there are many rewards to working at a small, critical-access hospital, those hospitals are having trouble attracting nurses like Harper. The entire region and, indeed, the nation are facing nursing shortages. But small towns like Davenport feel those staffing holes more acutely than many other areas.

At the heart of the issue for all health care facilities is a lack of capacity in the nursing educational pipeline. While plenty of people want to become nurses, the colleges and universities that educate and train them have had difficulty finding enough qualified instructors to teach them and sufficient clinical opportunities for those future nurses to get experience.

The pipeline problems for the nursing workforce in the state and in Spokane trickle down to surrounding counties, creating shortages in rural hospitals that are already faced with the geographic challenge of being more remote.

Most of the critical access hospitals surrounding Spokane have open RN positions, and some hospitals have been trying to recruit nurses for months.

While the statewide nursing shortage cannot be quantified yet, survey data from the Washington State Health Workforce Sentinel Network provides some clues. In three years of surveys from 2016 to 2019, critical access hospitals reported registered nurses as their top occupation with the longest vacancy.

While no single factor is to blame for the rural nursing shortage, recruitment of new nurses is a major challenge for some local rural hospitals in the Inland Northwest.

“My experience with rural nursing is that most people really interested come from those environments, and I think that’s the hard part: how do we get people to be excited if they’re not from there?” said Wendy Williams-Gilbert, a professor at WSU School of Nursing who practiced as a rural nurse.

Nursing educators say very few students express interest in practicing rurally, but for those who do, opportunities to go to rural settings for clinical work or practicum during their programs are also rare, compared to even a few years ago.

Brandi Maioho, director of nursing services at Lincoln Hospital, said about three years ago, the hospital arranged for nursing students to do their clinical or practicum hours in Davenport. Since then, though, schools have not renewed their contracts.

“For at least 10 years, we’ve struggled with really just getting ourselves known as an option,” Maioho said. “We used to have practicum nurses to come in, and we’d get them to work for us and stay working for us.”

Jennifer Larmer, who is now the hospital’s chief clinical officer, is a great example. She did her clinical hours at Lincoln Hospital during her BSN program at WSU. She understands some of the challenges nursing programs have getting students out to rural settings, but she also stressed the importance of students getting those experiences.

“It was not our choice to not have them (students). We’ve always been really willing and spent time dedicating staff to practicum nurses,” Larmer said. “And the challenge is, I think, the schools felt we couldn’t offer enough experience or guarantee the experience because we have peaks and valleys with our census, so we can’t always guarantee the number of patients or number of experiences they may have.”

Some nursing programs require nurses doing clinical hours to be supervised by a nurse with their BSN degree, which can also be harder to come by in a rural setting.

“We have to assure that they have the capacity and that they do have preparedness, and we shoot for baccalaureate-prepared nurses as their preceptor,” said Jo Ann Dotson, director of the BSN program at WSU.

She said WSU has contracts with lots of care facilities all over the state, and if a student is interested in a rural hospital or setting, faculty can work to create that opportunity for them. The majority of students want to do their clinical hours in acute-care settings in hospitals, however. Faculty members need to be able to work with and visit students doing clinicals, which can also present challenges when faculty are difficult to recruit.

There are fewer nurses in rural regions than in urban settings, even when adjusted for the populations living in those rural communities, a 2018 survey of nurses by the Center for Health Workforce Studies, at the University of Washington, found.

Some rural nursing positions require or strongly prefer candidates to have one to two years of experience before they work rurally. In Micah Kaluzny’s experience, his time working at Holy Family Hospital and Sacred Heart Medical Center prepared him well for his role as the emergency department manager in Colville at Mount Carmel Hospital.

“I am thankful I had the opportunity to work in the urban campuses because I got exposed to a lot,” Kaluzny said. “You see a lot of stuff in high, high volume. In one shift you see a lot more patients. I built a strong foundation there with my nursing skills.”

Kaluzny moved back to Colville, where he grew up, to work in Mount Carmel’s emergency department after a few years in Spokane. He is currently working on completing his bachelor’s degree in nursing online through Western Governors University.

Critical access hospitals seem to struggle less with retention and more with recruitment, because once nurses are working at one, they tend to stay. And nurses who have grown up rurally or have rural work experience have a greater likelihood of staying for a long time.

In Newport’s critical-access hospital, about two-thirds of nurses have been there for more than a decade, estimated Joseph Clouse, human resources director.

“If they live in the area, they tend to stay here,” he said.

Not all rural nurses started rural, though. Brenda Hulett grew up in the suburbs of San Francisco but is now working as a supplemental nurse at Lincoln Hospital when she is not teaching at WSU or Gonzaga or working on her Ph.D.

Hulett had worked in bigger hospitals and in clinics in Spokane and got her master’s degree at Gonzaga University too. But last summer, after realizing that she missed bedside nursing, she called up Lincoln Hospital, where she did her capstone project while she received her RN.

“I think one of the things I enjoy about it is you never know what you’re going to get when you go there,” she said. “Sometimes you go and deal with the long-term residents, which is fun because they all have their stories and quirks. … And other days, you’re on the acute side with patients coming in for a couple days, and really doing acute nursing care.”

Hulett will get to grow in her nursing practice by working as a supplemental nurse in Davenport, she said.

“I’m not trained for the ER, and this year they will train me for the ER,” she said. “Being in rural nursing, that’s the first stop for some people to get them stabilized before they get to an urban hospital.”

In Davenport, Maioho said staff and nurses grow and learn all the time. When nurses move departments internally, to surgery or different types of therapy, however, that leaves empty positions in their wake.

“It’s not that people are necessarily leaving, but when we have had an opening, it’s very difficult to fill that opening,” Maioho said.

Kaluzny echoed similar recruiting challenges in specialty areas, especially in the wake of retirements.

“Some of our most seasoned staff have retired, and now we’re working to fill those gaps,” Kaluzny said.

The hospital does “have openings,” he noted, “and we have struggled with finding candidates.”

While it’s easier to recruit locally, those recruits must get into nursing school, which is no easy feat locally. However, local nursing assistant training programs, which are often offered by the critical access hospitals to grow their own local workforce, can help.

Ultimately, rural hospital administrators and nurses say correcting the perception of rural nursing and health care for students and soon-to-be graduates is crucial.

“I think there’s a perception of rural health care that is a misconception. I think people sometimes think we sit and play cards and we aren’t knowledgeable and don’t provide adequate care, and I would say that the exact opposite is true for us,” Kaluzny said.

Many rural hospitals have loan-forgiveness programs for students, as well as organizational support for students furthering their education while they work. Administrators also debunked the idea that pay is significantly lower in rural areas.

“We don’t match it dollar per dollar, but we come pretty close,” said Clouse, in human resources in Newport.

Maioho said three nurses pursuing their master’s degrees are working at the hospital in Davenport now. Ultimately, a rural hospital can be a good training ground for all kinds of specialties, but not without support.

“We have more support than I think what people would anticipate in a critical access hospital, so you’re not the lone nurse,” Larmer said. “You’re there learning from others, and there is that support when we do have those critical cases come in.”