Rural Healthcare Workforce

Healthcare workforce is essential to providing healthcare access and quality in rural areas. Rural healthcare facilities must not only have an adequately sized health workforce, but those professionals must be able to meet the needs of the community in many ways, such as having proper licensure, education and training, and cultural competency skills. In addition, the use of, and coordination among, the workforce must be optimized to ensure that patients are getting the best care possible.

Strategies that can be employed include:

  • Implementing interprofessional care teams to provide efficient and coordinated care for patients and extend the reach of each provider
  • Ensuring that all professionals are fully utilizing their skill set and working at the top of their license
  • Removing barriers to practice, which exist at the state and federal levels, for established professions
  • Changing policy to allow alternative provider types once evidence shows they can provide quality care

As the nation struggles with shortages of healthcare providers, a maldistribution of those workers means that shortages are often more profound in rural areas of the country. This maldistribution of health providers is a persistent problem affecting the United States healthcare system.

This guide looks at the economics, policy, and planning issues and challenges related to rural health workforce, including:

  • Supply and demand
  • Distribution of the workforce
  • Characteristics of the rural health workforce
  • Licensure, certification, and scope of practice issues
  • Programs and policies that can be used to improve the rural health workforce

Frequently Asked Questions

Why is there a healthcare workforce shortage problem in rural areas?

Shortages of rural healthcare providers are in part a symptom of a national healthcare labor shortage. As stated in the National Rural Health Association (NRHA) policy brief, Health Care Workforce Distribution and Shortage Issues in Rural America, “the healthcare labor shortage in the United States has been widely documented and is expected to last for the foreseeable future.” The actual level of shortages can be difficult to determine since estimates for specific professions vary depending on their source.

The maldistribution of health professionals greatly affects rural communities. According to a Robert Wood Johnson Foundation policy brief, Primary Care Workforce in the United States, maldistribution is a more significant issue impacting primary care access than shortages of providers. Areas with higher proportions of low-income and minority residents, such as rural areas, tend to suffer from lower physician supply.

The following factors were identified in an interview with WWAMI Rural Health Research Center researchers and in the National Rural Health Association policy brief:

  • Education
    • The current education system tends to be urban-centric.
    • There is limited access to training and education programs in rural areas for those desiring to pursue careers in health fields in their communities.
    • Being trained in an urban area doesn’t necessarily prepare you to work in rural areas.
    • Urban areas draw people away from rural areas. Those in rural areas seeking a degree not offered online or through distance education often have to travel to an urban area. Once in an urban area, some providers may not go back to rural.
    • There are fewer medical role models for potential students in rural communities.
    • Rural students may have fewer opportunities to receive the math and science education required to pursue health careers.
  • Rural Demographics and Health Status
    • Rural areas carry a greater burden of disease, which creates more demand.
    • Rural areas tend to have higher rates of elderly population, who typically require more care.
  • Rural Practice Characteristics
    • The current healthcare system is designed around face-to-face contact. Patients from rural communities without certain types of providers, particularly specialists, must travel longer distances or forego receiving care.
    • In many rural areas, telehealth hasn’t been adopted yet due to reimbursement issues.
    • There are frequently fewer opportunities for health career advancement.
    • Understaffing can lead to increased workloads.
    • The work environment includes longer hours and less flexibility in scheduling.
  • Economics
    • Competition from urban facilities and practices can lure providers away for better salaries, benefits, and working conditions.
    • Aspiring rural students are less likely to come from a high socioeconomic status, making it less likely that they can afford medical school.
    • Small, rural communities offer few job opportunities for spouses, which can make recruiting providers difficult.

What are the characteristics of the current rural healthcare workforce?

Rural Primary Care Physicians

Those who reside in rural communities depend greatly on primary care providers as the leading source of healthcare.

According to Unequal Distribution of the U.S. Primary Care Workforce, for every 100,000 people who live in a rural area, there are 68 primary care physicians available to them. In urban areas, this number is 84 primary care physicians, with an estimated requirement being 80 per 100,000.

The primary care workforce is also experiencing problems related to workforce aging. According to a report from the WWAMI Rural Health Research Center, The Aging of the Primary Care Physician Workforce: Are Rural Locations Vulnerable?, the number of primary care physicians nearing retirement make up 27.5% of the rural primary care workforce, compared to 25.5% for the urban primary care workforce. In remote rural areas, this number is 28.9%.

Rural Physician Assistants (PAs)

ARHQ’s Primary Care Workforce Facts and Stats No. 3 tells us that, as of 2010, 15.5% of Physician Assistants practice in rural areas with 24.8% of primary care PAs in rural practice.

Rural Nurse Practitioners (NPs)

According to Understanding Advanced Practice Registered Nurse Distribution in Urban and Rural Areas of the United States Using National Provider Identifier Data, there are 2.8 rural Nurse Practitioners per 10,000 people, compared to 3.6 in urban areas. Male Nurse Practitioners were more likely to practice in rural – 8.9% of rural NPs are men compared to 6.8% in urban areas.

Rural Certified Registered Nurse Anesthetists (CRNAs)

According to Understanding Advanced Practice Registered Nurse Distribution in Urban and Rural Areas of the United States Using National Provider Identifier Data, there are 0.9 rural CRNAs per 10,000 people, compared to 1.2 in urban areas. Male CRNAs were more common in rural areas, with 60.9% of rural CRNAs being male, compared to 38.5% of urban CRNAs. Among rural CRNAs, there were 66.8% (3,645) practicing in large rural areas, 25.8% (1,410) in small rural areas, and 7.3% (400) in isolated small rural areas.

Rural Registered Nurses (RNs)

The growth of registered nurses nearing retirement age is also cause for concern. According to a report from HRSA, The U.S. Nursing Workforce: Trends in Supply and Education, rural RNs are:

  • Nearing retirement – Nearly one million RNs who are older than 50, about 1/3 of the current workforce, will reach retirement age in the next 10 to 15 years.
  • More likely to be white – 91.2% of RNs working in rural areas while compared to 72.4% of RNs working in urban areas.
  • Less educated – 51.6% of RNs working in rural areas have an associate’s degree or less as their highest degree compared to 35.3% of their urban counterparts.
  • More likely to work for a hospital – 59.4% of RNs working in rural areas are employed in hospitals compared to 63.9% of urban RNs.
  • Slightly older – The average age of a rural RN is 44.9 years, compared to 44.6 years for urban RNs.
  • About 16% of the RN workforce – From 2008 to 2010, there were 2.8 million RNs in the nursing workforce. Of that, 445,000 RNs live in rural areas, making up 16% of the RN workforce.

Rural Licensed Practical Nurses (LPNs)

According to a report from HRSA, The U.S. Nursing Workforce: Trends in Supply and Education, rural LPNs are:

  • More likely to be white – 83.2% of LPNs working in rural areas while compared to 56.9% of LPNs working in urban areas.
  • Less likely to work for a hospital – 28.8% of LPNs working in rural areas are employed in hospitals compared to 29.5% of urban LPNs.
  • More likely to work in a nursing care facility – 33.5% of LPNs working in rural areas are employed in nursing care facilities compared to 29.8% of urban LPNs.
  • Average age – The average age of both rural LPNs and urban LPNs is 43.6%.
  • About 24% of the LPN workforce – From 2008 to 2010, there were 690,000 LPNs in the nursing workforce. Of that, 166,000 LPNs live in rural areas, making up 24% of the LPN workforce.

What state-level policies and programs can help reduce and address the problems of rural healthcare workforce shortages?

Funding options states can use to address rural health workforce include:

  • Providing funding for health education including grants, loans, fellowships, and scholarships, state loan repayment/forgiveness scholarship programs, and faculty loan repayment programs
  • Increasing the numbers of healthcare graduates produced by state schools, by supporting the development and growth of healthcare education programs
  • Supporting rural residency programs
  • Assisting in recruitment and retention of healthcare providers for rural communities

Policy options states can use to address rural health workforce include:

  • Policy changes to remove barriers to practice, for example allowing telehealth services to be provided across state lines
  • Allowing new or alternative provider types more likely to provide services in rural areas

What can health professions schools and faculty do to meet rural healthcare workforce needs?

Some options available to educational institutions include:

  • Using admissions criteria that is likely to produce providers interested in working in rural, for example by admitting more students from rural communities
  • Offering curricula and training tracks specific to rural
  • Developing distance education programs

What strategies can rural healthcare facilities use to help meet their workforce needs?

Rural healthcare facilities can employ numerous strategies to ease healthcare workforce shortages. For instance, they can employ technology, such as telehealth to fill gaps in care caused by shortages. In addition, facilities can employ interprofessional care teams provide more efficient and high quality care. Redesigning practice and processes to allow each professional to work at the top of their license and skill set can also lessen the effects of shortages.

Rural areas often experience difficulties in the recruitment and particularly, the retention of primary care physicians and other health professionals. Because of this, it is very important for rural healthcare facilities to plan for their future workforce needs as much as possible. Being proactive, such as recruiting a new physician, NP, or PA before a primary care provider retires can help to avoid prolonged vacancies. Increasing pay, benefits, and flexibility can also improve chances for success with recruitment and retention efforts. See the Recruitment and Retention for Rural Health Facilities guide for ideas for successfully recruiting and retaining healthcare professionals.

How do foreign medical graduates help fill rural physician workforce gaps?

Many rural communities recruit foreign medical graduates with J-1 Visa Waivers to fill their physician vacancies. The Conrad State 30 Program allows each U.S. state’s health department to request J-1 Visa Waivers for up to 30 foreign physicians per year. The physicians must agree to work in federally designated health professional shortage areas or medically underserved areas. Interested parties should contact the Primary Care Office in the state of their intended employment for more information and exact requirements.

In addition to the J-1 Visa Waiver, a non-immigrant H1-B visa is a tool often used to fill an employment gap. The H1-B visa is an employer sponsored visa for ‘specialty occupations’ which includes the field of medicine and health. H1-B visas are initially for three years and can be extended to six years.

Where can I find statistics on healthcare workforce for my state including employment, projected growth and key environmental factors?

The National Center for Health Workforce Analysis provides in-depth data on supply, demand, distribution, education, and use of health personnel. State level profiles are available which provide data for 35 types of health workers.

The National Forum of State Nursing Workforce Centers provides a listing of state nursing workforce centers initiatives throughout the nation and in several states.

HRSA’s Area Health Resources Files (AHRF) provides demographic and training information on over 50 healthcare professions.

Occupational Employment Statistics: State Occupational Employment and Wage Estimates provides state information on occupational groups of interest within “Healthcare Practitioners and Technical Occupations” and “Healthcare Support Occupations.”

AAMC’s 2013 State Physician Workforce Snapshots provides data on current physician supply, medical school enrollment, and graduate medical education throughout the United States.

Kaiser Family Foundation State Health Facts: Providers and Service Use Indicators provides data on physicians, registered nurses, physician assistants, nurse practitioners, dentists, and total healthcare employment.

Robert Graham Center State Workforce Projections provides primary care physician workforce projection reports for all 50 states.

What are some federal policies and programs that have been designed to improve supply of rural health professionals and how effective are these programs?

Area Health Education Centers Program (AHEC)
AHEC programs consist of interdisciplinary, community-based training initiatives with the goal of improving the diversity, distribution, supply, and quality of healthcare personnel, particularly in primary care. The emphasis is on delivery sites in rural and underserved areas. AHECs act as community liaisons with academic institutions and assist in arranging training opportunities for health professions students as well as K-12 students.

Health Careers Opportunity Program (HCOP)
HCOP works to increase the number of individuals from economically disadvantaged backgrounds who enter the health professions field. HCOP programs provide student stipends and financial support to attend health professions schools, training for disadvantaged students, and counseling and mentoring services to help students complete their education and training. Students are exposed to community-based primary healthcare experiences.

National Health Service Corps (NHSC)
NHSC offers scholarships and loan repayments programs which enable students to complete health professions training. Students must complete a service commitment. Approximately 60% of NHSC placements are in rural locations.

Teaching Health Center Graduate Medical Education (THCGME)
Established by the Affordable Care Act, Teaching Health Centers provide residency training for dentists and primary care physicians in a community health center setting.

Rural Training Track Technical Assistance Program
Supports rural training track residency programs as a national strategy in training physicians for rural practice.

Sources: Statement by Tom Morris on Improving Federal Health Care in Rural America: Developing the Workforce and Building Partnerships, May 23, 2013; Office of Rural Health Policy Rural Guide to Federal Health Professions Funding, May 2012

Where can states get technical assistance for health workforce planning, including how to consider rural needs?

The Health Workforce Technical Assistance Center (HWTAC) can provide technical assistance to states and organizations who are working on health workforce planning. Activities of HWTAC to assist states include:

  • Direct technical assistance
  • Educational webinars
  • Facilitating access to health workforce data

HWTAC is a partnership of the Center for Health Workforce Studies (CHWS) at the School of Public Health, University at Albany, State University of New York, and the Cecil G. Sheps Center for Health Services Research at the University of North Carolina. It is funded by HRSA’s National Center for Health Workforce Analysis.

In addition, the National Governor’s Association is working with seven states to develop and implement statewide plans for their healthcare workforce. These participating states will receive technical assistance from NGA staff and faculty experts, private consultants, research organizations, and academia.”