Abstract
Background:
Despite nursing being the largest US health profession, only 16% of registered nurses (RNs) practice in rural areas, where health care access is limited. This significantly impacts rural residents, including over 2.7 million rural veterans receiving care at the Veterans Health Administration, leading to compromised health outcomes. Nurses are vital in primary care, improving coordination and management of chronic conditions.
Objectives:
Identify recruitment and retention programs for rural nurses (licensed vocational nurses/licensed practical nurses and RNs), including strategy characteristics and location.
Research Design:
We conducted a scoping review of published and gray literature. Eligible studies targeted US rural nurse recruitment and retention strategies.
Measures:
Data were extracted for program characteristics, including strategy type (eg, financial incentive), focus (recruitment, retention, or both), and collaboration levels (single or multi-institutional).
Results:
Of 1179 unique articles identified, only 60 met the inclusion criteria. An additional 42 programs were identified from gray literature, totaling 102 programs. Twenty-two programs used a multipronged approach (2–14 strategies), totaling 180 strategies. Education (n=85) and personal and professional support (n=54) were the most frequently used recruitment and retention strategies.
Conclusions:
Of the 102 programs, only 22 used a multipronged approach, with education as the most frequently used strategy. More programs should use a multipronged approach and provide additional incentives and support (eg, financial incentives) to rural nurses beyond education. Only 4 strategies were regulatory, shedding light on the need for more nurse recruitment and retention support at the policy level.
Key Words: nurse, recruitment, retainment, workforce development, rural
Approximately 20% of the US population lives in rural areas,1 yet these communities continue to face a critical maldistribution of health care providers,2 especially registered nurses (RNs). Despite their pivotal role in patient care, the ratio of RNs in rural to urban areas in 2022 was 64.1–97.9 (per 10,000 people), respectively,3 highlighting a stark workforce disparity.
This shortage of RNs is particularly problematic in rural communities, where residents are often older, experience higher rates of chronic illness, and have greater morbidity and mortality rates than their urban counterparts.4,5 Access to health care is a critical determinant of population health, and RNs play an essential role in facilitating this access,6,7 particularly within team-based primary care models.8,9 Nurses coordinate care for patients with complex needs, manage chronic conditions, educate patients, and triage urgent concerns, effectively extending the reach of providers.10–14 Evidence shows that higher nurse-to-population ratios are associated with improved health outcomes,8,15 making nurse availability a key lever for improving rural population health.
While physician workforce development has received considerable attention,5 the unique challenges faced by rural nurses remain underexplored. These challenges are multifactorial and include workforce attrition due to burnout, dissatisfaction, and poor work-life balance, compounded by lower wages in primary care and the urban-centric location of most nursing programs.16–18 In addition, rural nurses are typically older, less diverse, and often hold entry-level nursing credentials (eg, licensed vocational nurses [LVNs]/licensed practical nurses [LPNs] and Associate Degree in Nursing [ADN]) compared to their urban counterparts.19,20 These factors contribute to ongoing and projected nursing workforce disparities that further threaten health care access and outcomes in rural regions.6 As a central part of the health care team, nurses are critical to support the efficiency of physicians, and thereby serve a significant role in satisfaction and retention of physicians in rural areas.21–23 Therefore, it is paramount to recruit and retain rural nurses to foster a robust rural health care workforce to support a healthy ecosystem of care.8,12,13,15
The rural nurse shortage has significant implications for >50 million Americans, including 4.9 million veterans.3,24 Approximately 2.7 million of these veterans are enrolled in the Veterans Health Administration (VHA), the largest integrated health care system in the United States. With half of these rural veterans aged 65 or older and living with service-connected conditions and low income,3 the absence of accessible care directly compromises their well-being. With an extensive network of VA Medical Centers and Community-Based Outpatient Clinics in rural areas, the VHA has a notable influence on rural health care. In many rural communities with few physicians, nurses may serve as the primary or only point of contact with the health care system.25–27
The VHA is uniquely positioned to lead the development of sustainable, impactful solutions to strengthen the rural nurse workforce. To this end, our review sought to identify not only VHA-specific programs but also national and regional efforts outside the VHA that aim to recruit and retain rural nurses. By examining what is being done both within and beyond the VHA, we searched for promising practices and adaptable strategies that could be integrated into VHA programs. This broader perspective offers valuable insights to inform the design and implementation of future workforce development initiatives within the VHA and other rural health care organizations.
Scoping reviews are valuable for identifying knowledge gaps, organizing a body of literature, clarifying concepts, and analyzing research methodologies.28 This helps identify the types of rural nurse recruitment and retention programs that have been implemented. We focused on LVNs/LPNs and RNs rather than advanced practice nurses, such as nurse practitioners, since there is considerable variability in their scope of practice due to state-level policies.29,30
By reviewing publicly available resources and published literature, this project aimed to identify nurse recruitment and retention programs to better understand strategies used to develop the nurse workforce. Specifically, the project had 3 primary aims: (a) conduct a review to identify programs focused on recruiting and retaining nurses in rural areas, (b) compare program characteristics to understand incentives offered, and (c) identify whether such programs are located in rural areas with a shortage of primary health care providers since primary care is integral to health outcomes.31
Considering the significant impact of rural nurse shortages on rural residents’ and veterans’ health outcomes, this project aggregated recruitment and retention programs used to enhance nurse practice in rural areas. The 4 categories recommended by the World Health Organization (WHO; education, regulation, financial incentives, and personal and professional support) to enhance workforce development were used to categorize rural nurse recruitment and retention programs and their strategies.32,33 Through this comprehensive analysis, we examined the landscape of rural nurse recruitment and retention initiatives. This serves as a foundational step in addressing nursing shortages in rural areas by providing essential knowledge to inform both endeavors aimed at recruiting and retaining nurses in rural areas and ultimately improving health care accessibility in these underserved areas.
METHODS
Protocol and Registration
The protocol for this study has been registered with the Open Science Framework (https://osf.io/x257g).
This scoping review used the Arksey and O’Malley framework to guide our systematic exploration of the extant literature regarding rural nurse recruitment and retention incentives.34
Furthermore, to ensure the reporting of pertinent data, the protocol outlined by the Preferred Reporting Items for Systematic Review and Meta-Analysis—Scoping Reviews (PRISMA-ScR) was followed (Supplemental Digital Content 1, http://links.lww.com/MLR/D52).35
Eligibility Criteria
The research question was guided by the focal population (ie, nursing students, graduate nurses [ie, newly graduated nurses that have been authorized to practice as graduate nurses and authorized to test by the examination vendor], LVNs/LPNs, RNs);36 intervention (ie, rural nurse recruitment and retention programs); and setting (ie, retention of nurses in rural areas of the United States).
Search Strategy
The research team consulted with a professional Texas Medical Center medical librarian (BS) to formulate and execute a search strategy targeting published peer-reviewed literature. In addition, the gray literature was searched to establish a more comprehensive list of rural nurse recruitment and retention incentives that included websites and reports. On March 4, 2024, Medline Ovid was searched for literature on the topic of rural nursing recruitment and retention strategies in the United States, using MeSH headings (Rural Nursing, Rural Population, Rural Health Services, Rural Health, Medically Underserved Area, Nurses, Primary Care Nursing, Nursing Education, Personnel Selection) as well as the equivalent keywords, phrases, and truncated terms (Supplemental Digital Content 2 for an example search, http://links.lww.com/MLR/D53). This search strategy was then translated from Medline (Ovid) to Embase (Elsevier), PsycInfo (Ovid), CINAHL (Ebsco), and Web of Science (Clarivate).
To search the gray literature, reports identified in published articles were searched, as well as websites for programs mentioned in published articles, and a Google search was conducted. Terms used in the Google search were: rural nurse workforce development in the United States, excluding advanced and nurse practitioner. To identify specific VHA rural nurse recruitment and retention programs, a separate Google search was conducted using the terms: Department of Veterans Affairs (VA) recruitment and retention programs for rural nurses. Pages were searched until saturation was reached, defined as 3 consecutive pages with no new relevant programs.
Study Selection
The citations resulting from the search across databases were combined into an EndNote Library and de-duplicated within and between databases. These citations were imported into Covidence,37 and each title and abstract were reviewed by 2 independent screeners (KA, LA, or APR) for full-text inclusion. Conflicts were resolved by a third reviewer (HT). Articles with unavailable full texts were excluded. Those selected for full-text review were reviewed by 2 reviewers (KA, LW or APR) to determine whether to include the manuscripts in the study, and conflicts were resolved by a third reviewer (HT).
Studies were required to meet all 3 of the following criteria:
Focus on nursing students, graduate nurses, LVNs/LPNs, or RNs.
Aim to develop the rural nursing workforce in the United States.
Discuss a specific rural nurse recruitment or retention program.
Articles were excluded that did not:
Appear in English.
Have full-text available.
Explicitly discuss nursing students, graduate nurses, LVNs/LPNs, or RNs.
Focus on rural areas.
Discuss a specific rural nurse recruitment or retention program.
Provide sufficient detail regarding the program strategy or incentive to otherwise warrant a final determination of inclusion.
The study design was not relevant to the current review, as we were identifying rural nurse recruitment and retention programs and their characteristics.
Data Collection Process and Data Items
From articles satisfying the inclusion criteria during the full-text review phase, relevant descriptive data were extracted by 2 coders (KA, APR). Discrepancies were discussed with a third coder (HT) until consensus was reached. In reviewing the gray literature, programs meeting the inclusion criteria were added to the review. Some programs used multiple strategies; data were coalesced and extracted across both peer-reviewed and gray literature.
Data Synthesis
Descriptive data were extracted from each article or gray literature source and grouped thematically. Specifically, data were collected regarding:
Type of nurses targeted by the program (ie, nursing students, graduate nurses, LVNs/LPNs, or RNs).
Career stage of the nursing population targeted by the program (eg, high school or earlier, nursing student, practicing nurse).
State where the program is located.
Strategy category based on WHO guidelines (ie, education, regulation, financial incentive, or personal and professional development).32
Programs focus (ie, recruitment, retention, or both).
Institutional approach (ie, single institution or a multi-institutional collaboration).
Geographic Distribution of Recruitment and Retention Programs
A map was created using ArcGIS Pro 3.2.0.20 to visualize the geographic distribution of rural nursing recruitment and retention programs relative to rural primary care Health Professional Shortage Areas (HPSAs). Rural primary care HPSAs were identified using data from the Health Resources and Services Administration. These HPSAs are scored on criteria including the population-to-provider ratio, percentage of individuals living below the federal poverty level, infant health index, and average travel time to the nearest source of care, with scores ranging from 1 to 25, and higher scores indicating greater priority. Programs tied to specific institutions were plotted using the ZIP Code of the primary institution’s campus, if specified, or at the institution’s main campus if unspecified. State-level programs were displayed by outlining the state.
RESULTS
The literature search identified 1179 unique articles from Medline (Ovid), Embase (Elsevier), PsycInfo (Ovid), CINAHL (Ebsco), and Web of Science (Clarivate). After titles and abstracts were screened, 121 articles were selected for full-text review, and only 60 articles met the inclusion criteria. From the gray literature, an additional 42 programs were identified, for a total of 102 programs (Supplemental Digital Content 3 for a list of programs included, http://links.lww.com/MLR/D54). Of the 102 programs, 48 focused on recruitment, 17 focused on retention, and 37 focused on both recruitment and retention. Only 3 VHA programs appeared through the literature review (Fig. 1).
FIGURE 1.
PRISMA-ScR flow diagram. PRISMA-ScR indicates Preferred Reporting Items for Systematic Review and Meta-Analysis—Scoping Reviews.
Figure 2 is a US map that shows the geographic locations of institutional (n=68) and state-level (n=25) programs; however, it does not show national programs (n=9).
FIGURE 2.
Rural nursing recruitment and retention programs and rural primary care Health Professional Shortage Areas (HPSA).
Most programs (n=81) used a single strategy to recruit or retain rural nurses, but 22 programs used a multipronged approach employing 2–14 strategies. To provide a comprehensive look at the different strategies (n=180), the remaining results are stratified across all strategies versus at the programmatic level. Of the 180 strategies implemented to recruit and retain rural nurses 78 were focused on recruitment, 55 focused on retention, and 47 focused on both.
Education (n=85) was the most frequent strategy used, followed by personal and professional support (n=53) and financial incentives (n=53). Table 1 shows each strategy categorized by WHO category and further coded into subcategories. For example, the most common educational strategies used were preceptor, residency, or internship programs (n=27), followed by efforts to reach students with rural backgrounds (n=12). Within personal and professional support strategies, the most common were the implementation of shared governance programs (n=8), followed by mentorship (n=6), and public recognition measures (n=5).
TABLE 1.
Rural Nurse Recruitment and Retention Strategies Organized by World Health Organization Classifications and Subcategories
| WHO category | Subcategory | Frequency |
|---|---|---|
| Education | 85 | |
| Preceptor program/residency/internship | 27 | |
| Rural background student outreach | 12 | |
| Facilitate LPN to ADN or ADN to BSN | 11 | |
| Experiential learning | 10 | |
| Provides education access to rural students | 9 | |
| Distance learning | 7 | |
| Rural Health Interdisciplinary Program | 6 | |
| Specialized training | 5 | |
| Curricula that reflect rural health issues | 5 | |
| Continuing education | 4 | |
| Course for inactive nurses | 3 | |
| Accelerated ADN to BSN | 3 | |
| Expanded enrollment capacity | 1 | |
| Regulation | 4 | |
| Facilitate hiring | 1 | |
| Facilitate partnership | 1 | |
| Increase nurse programs | 1 | |
| Expanded enrollment capacity | 1 | |
| Financial Incentive | 53 | |
| Loan repayment with service time commitment | 17 | |
| Scholarship | 15 | |
| Scholarship with service requirement | 6 | |
| Salary increase | 5 | |
| Relocation pay | 1 | |
| Changed to salaried vs. hourly | 1 | |
| Immediate access to benefits | 1 | |
| Personal and professional support | 53 | |
| Shared governance | 8 | |
| Mentorship | 6 | |
| Public recognition measures | 5 | |
| Orientation | 3 | |
| Flexible schedules | 3 | |
| Outreach support | 3 | |
| Career development programs | 3 | |
| Implemented new nursing roles | 3 | |
| Easing RN burden | 3 | |
| Enhanced communication | 2 | |
| Nurse-friendly criteria | 2 | |
| Professional networking | 2 | |
| Childcare center | 1 | |
| Increase vacation time | 1 | |
| Reducing professional isolation | 1 | |
| Specialization | 1 | |
| Paid sabbatical | 1 | |
| Cohort admission | 1 |
Some strategies targeted multiple nurse types; therefore, the total count exceeds the total number of individual strategies.
ADN indicates Associate Degree in Nursing; BSN, Bachelor of Science in Nursing; LPN, licensed practical nurse; RN, registered nurse.
Eighty-seven strategies were sponsored by a single institution, and 93 were sponsored by 2 or more institutions. Table 2 shows the number of strategies that targeted specific nurse career stages, with practicing nurses (n=85) being the most frequently targeted career stage. In addition, most strategies focused on RNs (n=61), 20 focused on ADNs, and 33 targeted LVNs (Table 3).
TABLE 2.
Career Stage That Rural Nurse Recruitment and Retention Strategies Target (n=180)
| Career stage | Frequency (%) |
|---|---|
| Practicing nurse | 85 (43) |
| Nursing student | 65 (33) |
| New graduate nurse | 21 (11) |
| Nontraditional student | 11 (6) |
| High school or lower | 10 (5) |
| Re-entering practice | 5 (3) |
| Leadership | 1 (1) |
Some strategies were implemented at multiple career stages; therefore, the total count exceeds the total number of individual strategies.
TABLE 3.
Nurse Types That Rural Nurse Recruitment and Retention Strategies Target (n=180)
| Nurse type | Frequency (%) |
|---|---|
| RN | 61 (31) |
| Nurse (unspecified) | 49 (25) |
| BSN | 36 (18) |
| LPN/LVN | 33 (17) |
| ADN | 20 (10) |
Some strategies targeted multiple nurse types; therefore, the total count exceeds the total number of individual strategies.
ADN indicates Associate Degree in Nursing; BSN, Bachelor of Science in Nursing; LPN, licensed professional nurse; LVN, licensed vocational nurse; RN, registered nurse.
DISCUSSION
Our findings indicate that practicing nurses were the most frequently targeted stage for recruitment and retention strategies, followed by nursing students and new graduate nurses. This could suggest a growing recognition of the importance of engaging nurses early in their careers and fostering ongoing support to sustain their commitment to rural practice.
Aggregating rural nurse recruitment and retention strategy characteristics across 180 strategies revealed a diversity of approaches. Programs frequently targeted RNs, but a significant proportion of strategies were broadly open to all nurses, highlighting a potential opportunity for more tailored interventions. Most strategies were education focused, and a large subset of these were preceptor programs, residencies, or internships that were focused on helping graduate nurses transition into their first professional role. Many strategies also had elements of rural background student outreach, which included hosting nursing career fairs, having a class on health care careers, and an escape room for rural students in high school or lower.38
Financial incentives frequently included loan repayment or scholarships with service time commitments, as well as scholarships without a service time commitment. Importantly, most of the financial incentive subcategories (eg, loan repayment with service time commitment, scholarship with service time commitment, scholarships, relocation pay) are temporary financial incentives that are either a 1-time payment or are allocated to pay for nursing school. Only 5 strategies increased nurses’ pay, and one changed nurses' pay from hourly to a salary. To stay competitive as a field, nurses must be compensated in accordance with their training and responsibilities versus a 1-time bonus or payment that is a short-term solution.18,39
Personal and professional support strategies most frequently included incorporating shared governance in health care systems, where nurses provide input in decision making, such as work schedules, assignments, or potential programs. Six strategies used mentorship to help support nurses, and 5 used public recognition measures, such as recognizing outstanding nurses in the newsletter or during a meeting. Some strategies attempted to ease RN burden by hiring additional certified nursing assistants who could practice at the top of their license and perform additional tasks to free up RN’s time.
This review also highlights significant gaps in the literature and publicly available resources. For example, while many programs aim to enhance rural nurse recruitment and retention, the lack of robust evaluation reporting makes it difficult to determine the efficacy and scalability of these initiatives. Future research should prioritize the development and dissemination of evidence-based best practices to inform policy and program development. In addition, although some programs used a multipronged approach, combining several strategies to address the nuanced barriers to rural nurse recruitment and retention, few programs explicitly addressed mental health and well-being, an oversight that warrants further exploration, given the high rates of burnout and job dissatisfaction reported among rural nurses.8,40
The VHA plays a pivotal role in rural health care, given the high proportion of rural veterans relying on VHA services. The review identified a few programs specific to the VHA system, suggesting a need for greater investment and innovation in this area. Programs targeting rural veterans should consider the unique needs of this population, including their higher rates of chronic conditions, geographic isolation, and reliance on nurses as primary points of contact within the health care system.
Limitations and Future Directions
This review is not without limitations. First, the reliance on publicly available and published literature may have excluded relevant programs that are not well-documented or disseminated. Second, while the scoping review methodology provides a broad overview, it does not assess the effectiveness or outcomes of the identified programs, leaving gaps in understanding their impact. Third, the geographic mapping of programs relied on simplifying geographic data about institutional programs down to the locations of single institutions and generalizing state-level programs up to a simple outline of the states where programs were administered. This approach may not fully represent the reach of institutional programs or document most precisely where state-level programs make the most impact. Lastly, the inclusion criteria limited the review to programs explicitly targeting rural nurses, which may have excluded more general health care workforce initiatives that also benefit rural nursing.
Future research should focus on evaluating the effectiveness and scalability of identified recruitment and retention strategies to establish evidence-based best practices. This includes longitudinal studies to assess the sustainability of interventions and their impact on workforce outcomes. In addition, there is a need to explore innovative approaches to address mental health and well-being among rural nurses, given the high rates of burnout and turnover. Future research should explore potential unique protective factors and benefits associated with rural nursing to provide insight into ways to improve recruitment and retention. Expanding the scope to include interdisciplinary and community-based programs could also provide insights into holistic approaches to workforce development. Finally, targeted efforts to align program distribution with the most underserved areas, as identified by HPSA scores, would enhance the strategic impact of these initiatives. These directions will be essential in advancing the field and improving health care accessibility for rural populations.
CONCLUSIONS
The persistent shortage of rural nurses poses a significant challenge to the health and well-being of rural populations, including millions of veterans. This review provides a comprehensive overview of existing recruitment and retention programs, shedding light on their strategies, geographic distribution, and focus areas. The findings underscore the importance of multifaceted and targeted approaches to building a sustainable rural nurse workforce. The scarcity of program evaluations and mental health support identified a critical gap that future programs and strategies should focus on. By leveraging these insights, policymakers, educators, and health care organizations can better align efforts to meet the needs of rural communities and improve health care access and outcomes for underserved populations.
Supplementary Material
Footnotes
This work was funded by the Department of Veterans Affairs, Veterans Health Administration, Office of Rural Health, NOMAD #PRFY-04166. This work was partially supported by the use of resources and facilities at the Houston VA HSR&D Center for Innovations in Quality, Effectiveness and Safety (CIN13-413) and the South Central Mental Illness Research, Education and Clinical Center. The views expressed are those of the authors and not necessarily those of the Department of Veterans Affairs, the US Government, or Baylor College of Medicine.
This work was presented at the National Rural Health Association’s 47th Annual Conference in May 2024.
The protocol for this study has been registered with the Open Science Framework (https://doi.org/10.17605/OSF.IO/X257G).
The authors declare no conflict of interest.
Supplemental Digital Content is available for this article. Direct URL citations are provided in the HTML and PDF versions of this article on the journal's website, www.lww-medicalcare.com.
Contributor Information
Kelley Arredondo, Email: Kelley.Arredondo@bcm.edu.
Laura Witte, Email: laura.witte@va.gov.
Alexander Paterson-Roberts, Email: azpaters@CougarNet.UH.EDU.
Alexandra Caloudas, Email: Alexandra.Caloudas@va.gov.
Matthew Vincenti, Email: Matthew.Vincenti@va.gov.
Bradley V. Watts, Email: Bradley.Watts@va.gov.
Bronwyn Sutherland, Email: bronwyn.sutherland@library.tmc.edu.
Hilary Touchett, Email: hilary.touchett@va.gov.
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