Voices from the Frontlines: A New Graduate Nurse in Rural America

Melanie* is a former student who took a job in a rural hospital, deciding she would rather have a job sooner than later so her career could begin moving forward after graduation.  In a recent letter, she reflected on her first year's experiences.

"The hospital has its pluses and minuses - I always, quite often, remember what you said to me about how accepting this job would be wise in my long-term plan, because it would give me an understanding of how different systems work in different areas. It really has done so. It has been an eye-opening journey into the difficulties rural health systems face.

Rural hospitals have unique challenges that come from both their revenue sources and the locally available talent pool.  They can be great places to get experience with a wide range of patients.

     "The good: The step down unit is 24 beds, with a ratio of 4:1. Because of the hospital's small size and inability to specialize, it's a kitchen sink as to what we get, which skills and experience-wise has been undeniably great. Lots of cardio stuff, most people on tele, CABG, PCI,  pacemakers etc - those are the best patients. Tons of fresh strokes, lots of run-of-the-mill but more end-stage COPD, CHF. Surgically we get everything that the other floors won't take: fem-pops, abdominal surgeries, could be anything. Lots of end-of-life palliative/comfort care, too." 

There are also challenges, but like urban hospitals, most of the time they come down to the quality of management.

       "The bad: Staffing is terrible. There are many nights when the floor has no aide, or only 1 aide.We are supposed to always have 2, which can be insufficient at times even.  I try to always help out the ones we are lucky enough to get when they're around because they are overworked, but sometimes, as you know, you just can't do everything. It's frustrating and burnout-inducing when you are trying to tend to your patient whose vitals are changing and they're having an acute change in condition, and have to simultaneously take vitals and toilet your other patients. It's just physically impossible most of the time. When you get 4 total-care, incontinent, confused, very sick patients, it's just impossible. I try not to be a baby and just take a deep breath and do my best, but there are some mornings where I get home and just bawl because it's just too much. Other RNs do our absolute best to help each other out, but everyone's patients are sick and needy. The hospital has ridiculous RN turnover because of this." 

Melanie has been in her job less than a year and she recognizes signs of burnout in herself.  Turnover is really your best indicator of how well a hospital manages its nurses.  Management practices can affect the hospital in other ways.

       "We just lost Magnet status and I (professionally, politely) told my nurse manager at a staff meeting that this is not shocking and I saw it coming from a mile away. Our nurses don't have the support they need to do their job, leave in droves every year, feel burnt out and underpaid, among other things. No one on staff was surprised that we lost this designation. The hospital insists it's working on beefing up ancillary staff, especially on nights, but it has yet to happen. Part of it is because pay is crappy - we make shy of 25/hr with night differential. Larger cities about an hour or two away from here all pay well over 30/hr. Many nurses who have kids and families and are more settled in the area end up at these hospitals." 

Melanie's annual salary works out to just over US$50,000 per year while nurses a short distance away are making around $60K.  Yes, you can say that cost of living differences would make things cheaper in a rural area, but gas prices are slowly eliminating cost of living differences in the part of the country where she works.  Unfortunately, Melanie knows she won't stay at the rural hospital, just 9 months into her job.

      "I'm incredibly grateful to have gotten this job and be obtaining the kind of versatile, varied experience I'm getting. I recognize that the facility does the best it can with what it's got sometimes. However, I feel on the whole it's got a lot of improving and waking up to do. I look forward to maybe transferring to a bigger, more urban hospital with hopefully better staffing patterns, and a little more organizational appreciation for the work nurses do. Not sure where I will go next."

Melanie's situation could just as easily have occurred in an urban setting.  No matter where you go, nurse turnover is costly and drives up the price of patient care.  A nurse has to work at a hospital for two years for the hospital to recoup the recruitment and orientation costs from the initial hire. Not all new graduates leave in their first year and many do so for other reasons than management, , as a study by Brewer et al (2012) demonstrated.

Perhaps one thing the any healthcare system can do is work on their management techniques to promote retention and reduce turnover.  That alone could generate millions in cost savings.

*Names and locations have been changed.