The importance of NP contributions to rural communities is longstanding. Medicare direct reimbursement to NPs was first authorized in 1990 for NPs only in areas designated as rural.1 NPs in 2016 represented more than 25% of providers in rural areas—an increase from 17.6% in 2008.2 During this time period, the percentage of physicians practicing in rural areas declined 12.8%, while the percentage of physician assistants (PAs) had a nonsignificant increase from 13% to 14.4%.2
The American Association of Nurse Practitioners' Nurse Practitioner Compensation 2019: Results fromthe National Nurse Practitioner Sample Survey reports that nearly 12% of all NPs work in communities with a population of less than 10,000; another 20% work in communities with residents between 10,000 and 49,999, some of which may be considered rural.3 Data from the 2012 National Sample Survey of Nurse Practitioners indicated higher proportions of NPs practice in rural areas in states without physician oversight requirements.4 Compared with urban NPs, rural NPs also more often reported practicing to the full extent of their legal scope, being satisfied with their work, and planning to stay in their jobs.4 NPs in rural practice can serve as advocates to eliminate health disparities for people in their communities while working in a practice environment that values the NP role.
What is rural?
Federal agencies have differing definitions of rural. The United States Census Bureau estimates that 19.3% of the population is rural, while the United States Office of Management and Budget estimates the same to be 15%.5,6 In response to this variance, the Rural Health Information Hub has developed a tool to determine if a community is considered rural using multiple definitions based on the community's eligibility to receive certain federal funds.7
Regardless of the variance in definitions, health disparities exist between rural and urban communities and tend to be more significant the more remote the community. NPs play a vital role in overcoming these health disparities. Knowing whether a community is considered rural allows an NP to determine eligibility for loan repayment, grants, and enhanced reimbursement.
Health disparities among rural populations
Demographic, environmental, economic, and social factors all place rural residents at higher risk of death from conditions such as heart disease, cancer, unintentional injuries, chronic lower respiratory disease, and stroke.8 Residents of rural areas in the US tend to be older and sicker than their urban counterparts and have higher rates of cigarette smoking, hypertension, and obesity.8 Rural residents also have higher rates of poverty, less access to healthcare, and are less likely to have health insurance than urban residents.8 Although the prevalence of people with mental illness is similar between rural and urban areas, insufficient services in rural areas create disparity.9
Substance use disorder
Another increasingly important health disparity in rural communities is services for substance use disorder. Factors contributing to substance use in rural America include low educational attainment, poverty, unemployment, high-risk behaviors, and isolation.10 In 2015, the rate of death (per 100,000 people) from drug overdoses in rural areas exceeded the rate in urban areas for the first time.11 From 2016 to 2019, NPs and PAs accounted for more than half of the 111% increase in waivered clinicians (those with approval from the Drug Enforcement Administration to prescribe buprenorphine for the treatment of opioid use disorder) in rural areas. NPs and PAs were also the first waivered clinicians in 285 rural counties with 5.7 million residents.12
Barriers to care
Barriers to care for those in rural communities include the distance to services, lack of reliable and affordable transportation, low health literacy levels and perceptions of health, lack of insurance, and high poverty rates that make payment for services difficult.13 Barriers to care are an important issue for those with chronic conditions, such as diabetes, which affects 30 million people—nearly 1 in 10—in the US. Diabetes self-management education and support programs that improve health outcomes are not available in 62% of rural counties.14
Both insured and uninsured people in rural areas have challenges accessing care due to workforce shortages. The Health Resources and Services Administration (HRSA) designates Health Professional Shortage Areas (HPSAs) into several different categories, such as geographic, population, and facility HPSAs. HRSA also uses medically underserved areas and medically underserved population designations and certifies requests from governors for rural health shortage areas.15
Almost every state has entire counties that are mental health or primary care HPSAs; few states have no counties without a shortage.16,17 The shortages are more dire for mental health than primary care. The overall behavioral health workforce is inadequate in rural areas, and the number of psychiatric NPs who work in rural communities with less than 10,000 people is an estimated 0.9 per 100,000 people, which is the smallest of any behavioral health profession.18
Increasing the rural NP workforce
NPs make significant contributions to the health of people living in rural areas. As demand for primary and behavioral health increases, NPs are poised to be part of the solution to rural workforce shortages.
There is little evidence regarding effective strategies to recruit and retain NPs for rural practice. Two strategies identified in studies that are likely to be successful in recruiting NPs to rural sites include scholarships and loan repayment programs and the inclusion of rural didactic content and clinical practicum experiences in NP education programs.19-22 Rural connectedness with support networks, professional and community relationships, as well as having lived in a rural area prior to becoming an NP are important factors for NP retention in rural communities.19,23 Building the rural NP workforce through projects that use foundation, community, and employer support to recruit registered nurses living in rural areas to attend NP programs is a creative strategy being used in Colorado.24 A strong rural NP workforce can meet the needs of rural communities and decrease health disparities. NPs who work in rural communities serve as advocates through their practice.
1. Omnibus Budget Reconciliation Act of 1990. P.L. 101-508(104 Stat. 143). 1990. www.ssa.gov/OP_Home/comp2/F101-508.html
2. Barnes H, Richards MR, McHugh MD, Martsolf G. Rural and nonrural primary care physician practices increasingly rely on nurse practitioners. Health Aff (Millwood)
3. American Association of Nurse Practitioners. Nurse practitioner compensation 2019: results from the national nurse practitioner sample survey. 2019.
4. Spetz J, Skillman SM, Andrilla CHA. Nurse practitioner autonomy and satisfaction in rural settings. Med Care Res Rev
5. Ratcliffe M, Burd C, Holder K, Fields A. Defining rural at the U.S. Census Bureau: American Community Survey and geography brief. 2016. www2.census.gov/geo/pdfs/reference/ua/Defining_Rural.pdf
6. Health Resources and Services Administration. Defining rural population. 2018. www.hrsa.gov/rural-health/about-us/definition/index.html
7. Rural Health Information Hub. Am I rural? – Tool. www.ruralhealthinfo.org/am-i-rural
8. Centers for Disease Control and Prevention. Leading causes of death in rural America. 2019. www.cdc.gov/ruralhealth/cause-of-death.html
10. Rural Health Information Hub. Substance abuse in rural areas. 2018. www.ruralhealthinfo.org/topics/substance-abuse
11. Mack KA, Jones CM, Ballesteros MF. Illicit drug use, illicit drug use disorders, and drug overdose deaths in metropolitan and nonmetropolitan areas - United States. MMWR Surveill Summ
. 2017;66(19):1–12. www.cdc.gov/mmwr/volumes/66/ss/ss6619a1.htm
12. Barnett ML, Lee D, Frank RG. In rural areas, buprenorphine waiver adoption since 2017 driven by nurse practitioners and physician assistants. Health Aff (Millwood)
13. Rural Health Information Hub. Barriers to health promotion and disease prevention in rural areas. n.d. www.ruralhealthinfo.org/toolkits/health-promotion/1/barriers
14. Centers for Disease Control and Prevention. Diabetes self-management education and support in rural America. 2018. www.cdc.gov/ruralhealth/diabetes/index.html
15. Health Resources and Services Administration. Shortage designations: types of designation. 2019. https://bhw.hrsa.gov/shortage-designation/types
16. Rural Health Information Hub. Health professional shortage areas: mental health, by county, 2019. 2020. www.ruralhealthinfo.org/charts/7
17. Rural Health Information Hub. Health professional shortage areas: primary care, by county, 2019. 2020. www.ruralhealthinfo.org/charts/5
18. Larson EH, Patterson DG., Garberson LA, Andrilla CHA. Supply and distribution of the behavioral health workforce in rural America. Data Brief #160. Seattle, WA: WWAMI Rural Health Research Center. 2016. https://depts.washington.edu/fammed/rhrc/wp-content/uploads/sites/4/2016/09/RHRC_DB160_Larson.pdf
19. Fairbanks J, Montoya C, Viens D. Factors influencing the recruitment and retention of nurse practitioners into rural, underserved, and culturally diverse areas. Am J Nurse Pract
20. Kippenbrock T, Stacy A, Gilbert-Palmer D. Educational strategies to enhance placement and retention of nurse practitioners in rural Arkansas. J Am Acad Nurse Pract
21. Owens RA. Transition experiences of new rural nurse practitioners. J Nurse Pract
22. Pathman DE, Konrad TR, Hooker RS. Physician assistants and nurse practitioners in the National Health Service Corps. JAAPA
23. Conger MM, Plager KA. Advanced nursing practice in rural areas: connectedness versus disconnectedness. Online J Rural Nurs Health Care
24. Johnson IM. A rural “grow your own” strategy: building providers from the local workforce. Nurs Adm Q