Different challenges in urban and rural nursing jobs

April 7, 2021

Blyss Splane

What is the main difference between urban and rural nursing? 

Nurses can pursue countless opportunities after graduation. When deciding where to apply for a job, there are an abundance of factors to consider. One of the biggest considerations is whether to work in an urban or rural environment. Each location comes with benefits and challenges that may be a better fit for one nurse over another. Additionally, characteristics and requirements will vary by setting. 

The main difference between urban and rural nursing is the location of work. These settings are identified as urban, rural, and frontier regions. 

Urban is defined as “the region surrounding a city” and includes concentrated numbers of human structures such as houses, commercial buildings, and transportation infrastructure. Urban areas include cities, towns, suburbs, and large metropolitan areas. 

Rural is loosely defined as “the country” and encompasses substantial amounts of undeveloped land and areas with less than 2,500 people or fewer than 500 people per square mile. Located within rural areas, frontier regions are areas with fewer than 6 people per square mile.  

Frontier regions may also have more than 6 people per square mile, but these are considered isolated and remote due to the distance in miles or travel time to access services. 

Education requirements and places to work  

Nursing experience is required to work in an urban setting. Alternatively, new graduate nurses may enter a nurse residency for orientation. An associate’s or bachelor’s degree in nursing must be obtained before sitting for the National Council Licensure Examination (NCLEX exam). Once a new graduate nurse has passed the NCLEX, they can apply for a nursing position. On-the-job training is an important component of both urban and rural nursing jobs.  

Nurses in urban locations can choose to work in a variety of settings including competing large hospital systems, clinics, urgent care centers, outpatient surgery, schools, and public health or government agencies. City jobs are considered fast-paced and innovative, as the hospitals typically have access to the  newest technology and offer good remuneration. There is a significant amount of diversity across interdisciplinary staff roles in urban locations. These include physicians, residents, nurse practitioners, physician’s assistants, and ancillary staff such as respiratory therapists and laboratory technicians. 

In rural locations, nurses may work in smaller community hospitals, clinics, schools, urgent care centers, as well as for government agencies. The options are slimmer in rural areas due to the distance or remoteness of the area. Many of these communities are drastically underserved with limited or no access to healthcare. Many rural locations do not have a physician, which leaves only a nurse practitioner to see patients. Other locations might have several different healthcare providers, but not an abundance of ancillary staff. 

Orientation 

Orientation in an urban setting is typically longer and more structured with a focus on a specialty such as pediatrics, oncology, or labor and delivery. The high volume of specific patient populations allows for the repeated practice of nursing skills to build expertise. Specialty certifications may be required before starting a job or obtained within a certain period after being hired. New nurses might have access to several different preceptors during the orientation process. 

Rural hospital nursing orientation can be dramatically shorter, as the unit may be short-staffed. There is not the same volume of similar patient populations to learn specific skills or care through repetition. Nurses are oriented as generalists with a focus on gaining competencies within many different specialties across the patient’s lifespan, as opposed to a singular specialty. Nurses with emergency room experience are highly sought after in recruitment for rural areas because their skillset can treat a wide variety of illnesses, trauma, and complications. 

Commuting challenges for rural versus urban nursing 

Significantly different challenges exist within rural and urban nursing. This distinction stems from the location where nurses work. Depending on how remote the location is for a rural nurse, the commuting-related challenges may include inclement weather, extended distances from home to work, and the risk of treacherous roads.  

On the other hand, nurses working in urban locations have a separate set of commuting issues. While there might be major highways to commute to work, increased amounts of traffic are likely. Nurses may also need to live farther from the city to afford housing, as the cost of living in the city can be more expensive. Many city hospitals have limited parking space, require payment to park, or offer parking in a lot that is far from the hospital. While these may not be make-or-break factors when selecting a job, they are worth considering. 

Do nurses get paid more as rural nurses? 

The hourly wage for nurses varies widely across the country and depends on the specific location. Metropolitan hospitals in urban areas are typically better funded, which allows for higher salaries. With additional funding, urban areas can work to retain nurses by offering more competitive insurance, benefits, and pay. Large institutions are also more likely to leverage  sign-on bonuses as a way to attract talent to their facility. 

One of the challenges of rural nursing is effectively retaining nurses to address shortages in these geographically isolated or remote areas. While rural nursing jobs may offer lower pay, additional benefits have been implemented over time through policy changes and legislation. Examples of these benefits include utilizing federal funding to expand nursing school access and reducing student loan rates. In addition to scholarships, some rural hospitals offer student loan repayment options and aim to increase their benefits packages as a way to balance out lower wages. 

Skills and characteristics of rural and urban nurses

The demographics of nurses who work in rural locations can vary significantly. Rural and frontier areas have fewer employed nurses with research samples illustrating “an older and less educated employee than those in urban studies.” This results in lower ratios of registered nurses to licensed practical nurses in rural areas. Another study of rural nurses indicated “that younger nurses were unwilling to continue working in environments that limit their ability to hone specialized skills, practice to the full scope of their role, and obtain full-time employment.” They believed that younger nurses’ career goals led them to work in urban areas. 

Rural nursing jobs involve higher expectations that new graduate nurses may not immediately meet after starting their first job. Crisis assessments and the management of patients across all severity of illnesses and injuries throughout the lifespan require an advanced set of nursing skills that are learned over time. The expectation of cross-discipline assessments creates a challenging work environment for new nurses, in comparison to urban nurses who are orienting to a single specialty. Rural nurses are expected to be expert generalists and become comfortable with working autonomously and independently as there may not be many other healthcare providers nearby. Rural nurses must be critical thinkers and use their creativity to help patients achieve their best possible outcomes. 

It’s common for new graduate nurses to seek out fast-paced urban hospitals with specialty units, higher wages, increased benefits, better insurance, and potential sign-on bonuses. Nurses in urban centers work interdependently with various healthcare providers and numerous resources. Physicians in urban areas are more likely to be in the hospital when on-call, whereas a physician may be at home while on-call in rural areas.  

The reasons for not seeking healthcare varied, but urban participants were more likely to report a lack of knowledge around where to go, concerns about prescription drug cost, cultural misunderstandings, language barriers, unwelcoming health care facilities, and unfair treatment based on race.

Lifestyles of rural and urban nurses  

Nurses who work in urban locations have greater access to restaurants, bars, shopping, and large social events. With higher amounts of employees available, units are more well-staffed than in rural areas. This leads to increased stability in scheduling, with enough staff to cover weekends and holidays. The rapid pace of urban environments enables nurses to care for patients with higher acuity illnesses and injuries. 

Rural nurses are more likely to have grown up in a rural location and favor an adventurous lifestyle. There is strong community engagement in a small town, which requires nurses to focus on patient confidentiality within the community. While rural nursing can be challenging, there are also many personal and professional rewards involved in serving a small community. Rural nurses may not be employed full-time and instead work multiple part-time jobs to meet their family’s financial needs. Partners of rural nurses might also not have the same professional opportunities in a small town, requiring the nurse to take on more hours. 

Rural versus urban healthcare access 

The patient populations of rural and urban areas have a unique set of characteristics and demographics. “Rural residents generally have a lower annual income, less education, and overall poorer health status than their urban counterparts,” according to a study by Bushy (2006).  

Further, Molinari et al.(2008) reported that typically, rural residents suffer from more chronic diseases and more occupational health issues” such as being elderly and obese, having less healthcare insurance, and purchasing more expensive medications. The geographic locations may limit how frequently these populations can access healthcare services—whether they live in a healthcare provider shortage area (HPSA) or have access to specialty care providers. 

One key challenge of rural healthcare is the abundance of HPSAs. These are areas with a shortage of providers for primary, dental, or mental health care. This limitation decreases the likelihood of healthcare access, as rural residents may have to travel even farther to seek healthcare for a provider who may be out-of-network. The transportation fee and increased costs for seeking healthcare out-of-network can be an additional deterrent. 

According to a 2018 study by Loftus et al., “approximately 24% of the rural population reported no past-year use of preventative care compared to just under 19% of the urban population.” The reasons for not seeking healthcare varied, but urban participants were more likely to report a lack of knowledge around where to go, concerns about prescription drug cost, cultural misunderstandings, language barriers, unwelcoming health care facilities, and unfair treatment based on race. This research demonstrates that while there are many physical locations available to urban residents, significant barriers around obtaining healthcare access remain. 

What are unique nursing issues in rural hospitals? 

While the nursing shortage is a nationwide issue, it has a particularly dramatic effect on rural settings. Isolation, fewer resources, sparser populations, and reduced financial incentives limit the recruitment of nurses to rural locations. Nursing units in these areas can be drastically understaffed, which requires asking nurses to work more overtime hours or bringing in travel nurses to meet demands.  

As many smaller hospitals function as a general healthcare facility for a wide range of people, patients with a critical illness or other serious conditions are routinely stabilized and then sent to larger tertiary centers for specialty treatment. With fewer healthcare providers, nurses must function more independently and maintain a strong understanding of their state’s nurse practice act to guide their decision-making processes.  

Patients in remote or isolated areas are more likely to have chronic illnesses that go untreated for long periods of time. These individuals may not seek treatment until their situation is dire, which can lead them to be transferred to a large hospital even farther from their home for advanced treatment. 

Potential solutions to rural healthcare issues  

Due to the unique challenges that rural healthcare facilities encounter, solutions must be specific to these issues. Nursing programs should familiarize students with the generalist approach needed for success in rural areas. Education beyond medical-surgical basics is a requirement for nurses who wish to work in these settings.  

Nurses who work in remote or isolated areas should aim to join support groups and professional organizations for rural healthcare providers. It’s important to stay connected with other providers who may be encountering similar experiences and challenges. This can ultimately help prevent burnout or professional isolation.  

Federal funding and grants for rural and frontier areas continue to assist in improving the amount of providers that work in these locations. Education grants increase the number of people who can attend baccalaureate nursing programs and enable additional technology purchases for these programs. Practice grants incentivize healthcare providers to work in medically underserved communities to help increase access. Nursing student loan forgiveness plans, tuition repayment programs, and scholarships serve as a way to assist lower income applicants with paying off student loan debt. 

While funding and policy changes aim to recruit nurses and healthcare professionals to medically underserved areas, nurse retention in these facilities remains essential. The 2008 study by Molinari et al., found that rural nurses were more satisfied with their jobs when they had flexible work hours that support family lifestyles and encouragement around staff communication. Adequate staffing allows for more coverage of shifts and less scheduling problems to give nurses the manageable schedule they need for work-life balance.   

The role of rural and urban communities in public health 

Both rural and urban roles can be considered community or public health nursing. In rural areas, public health nursing typically centers on the needs of the community. Rural nurses aim to become familiar with the local residents and social dynamics to plan the right education and interventions to meet the community’s health needs. For instance, the nurse may notice that the majority of patients suffer from type 2 diabetes and require additional education around diet and exercise to mitigate the use of insulin. This is an example of public health or community nursing. 

In urban settings, public health covers a much wider range of health issues and education across a larger scale and greater amount of people. For instance, a portion of the population might suffer from high blood pressure and many others are unaware that they have it. An urban public health or community nurse might decide to do a blood pressure drive, giving people the opportunity to be screened for high blood pressure and directed to the appropriate medical services if necessary.  

The benefits and challenges of community nursing can vary by location. The advantages for both types include: 

Addressing health needs of the local community 
Providing education that residents may not receive otherwise 
Working closely with the community to promote better health 
Flexible work hours and schedule 

The disadvantages of community nursing include: 

The challenge of meeting the community’s public health demands  
Residents’ lack of insurance or expensive insurance 
Difficulty of planning for a wide variety of health issues 
Location of planned events and how far residents live from them  
Inadequate staffing, leading to burnout and high stress levels 
The presence of violence
Limited opportunities for career advancement 
Professional isolation 

The key takeaways  

Every new graduate nurse will ultimately have to decide between working in an urban or rural environment, and it’s important to consider several factors before moving forward. Each location offers benefits and challenges that might be ideal for one nurse and a headache for another. The nursing shortage may affect both areas, but rural nurses take on a greater responsibility to staff their units as there are far fewer nurses in these settings.  

Urban nursing offers the benefits of increased pay, the ability to work with a specific patient population, career advancement, plentiful resources, and interdisciplinary team members. Therefore, this may be the appropriate choice for many nurses. While urban nursing also comes with challenges, they are drastically different from the issues that rural nurses face.  

For nurses who are interested in working in rural areas, it’s important to consider how isolated or remote they wish to be. They should also determine whether they have the right temperament for the role. This includes an appreciation for the outdoor lifestyle, a desire to be autonomous and independent, and a willingness to learn the necessary skills to become an expert generalist. Rural nurses have the opportunity to care for patients across all stages of life and gain experience treating a wide range of diseases. The variety and community camaraderie are 2 of the biggest benefits of working in rural areas.  

Regardless of the chosen location, nurses are needed across the country to promote the health of many different populations. Weigh your options carefully and keep in mind that a change can still be made during most points of your nursing career. While urban nursing offers several perks, there is still a significant shortage of nurses in rural and underserved medical areas. With the right training and mindset, nurses can pursue rural nursing with the confidence that they made the right decision. 

Bushy, A. (2006). Nursing in rural and frontier areas: issues, challenges and opportunities. Harvard Health Policy Review, 7(1), 17-27. http://www.hcs.harvard.edu/~hhpr/wp-content/uploads/2012/05/Bushy.pdf

Health Resources & Services Administration. (January 2021). What is Shortage Designation? https://bhw.hrsa.gov/workforce-shortage-areas/shortage-designation 

Loftus, J., Allen, E. M., Call, K. T., & Everson‐Rose, S. A. (2018). Rural‐urban differences in access to preventive health care among publicly insured Minnesotans. The Journal of Rural Health, 34, s48-s55. 

Molinari, D. L., & Monserud, M. A. (2008). Rural nurse job satisfaction. Rural and remote health, 8(4), 1055.https://pubmed.ncbi.nlm.nih.gov/19061306/ 

Montour, A., Baumann, A., Blythe, J., & Hunsberger, M. (2009). The changing nature of nursing work in rural and small community hospitals. Rural and remote health, 9(1), 1089. https://pubmed.ncbi.nlm.nih.gov/19199373/ 

Rosenblatt, R. A., Casey, S., & Richardson, M. (2002). Rural–urban differences in the public health workforce: local health departments in 3 rural western states. American Journal of Public Health, 92(7), 1102-1105. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1447195/

Rural Health Information Hub. (June 2, 2020). Health and Healthcare in Frontier Areas https://www.ruralhealthinfo.org/topics/frontier

Rural Health Information Hub. (November 9, 2020). Rural Healthcare Workforce https://www.ruralhealthinfo.org/topics/health-care-workforce

Terry, D., Lê, Q., Nguyen, U., & Hoang, H. (2015). Workplace health and safety issues among community nurses: a study regarding the impact on providing care to rural consumers. BMJ open, 5(8), e008306.  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4538262/ 

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