Insights for rural hospital leaders on nurse retention and job satisfaction

Rural and critical access hospitals are often the main source of health care for rural communities, providing essential services with fewer resources than facilities in urban and suburban areas. Nurses in these hospitals take on multiple roles, develop deep connections with patients, and overcome unique challenges. Nurses are an essential part of the delivery of high-quality patient care, and hospital leaders must understand what is important to them and what drives their job satisfaction. 

It is expensive for rural hospitals to recruit, train, and hire nurses. According to the 2024 Nursing Solutions Inc. national health care retention and RN staffing report, the cost to replace just one nurse in 2023 was $56,300. Additionally, RN turnover in the first year of employment sat at 23.8 percent, emphasizing the importance of investing in job satisfaction, especially early on. Taking action on nurse feedback will reduce turnover, lower recruitment costs, decrease investment in time and money to train new staff, lower staff burnout, and lead to better patient care.

Rural hospital nurses who have worked both staff and agency jobs offer insights on what drives their job satisfaction, uncovering ideas on how to attract and retain rural nurses.

What rural nurses love about their job

A close-knit community

Many rural nurses described their workplace as a family. “Being a part of a close-knit family, knowing all the staff and most patients that come in,” one nurse said when asked what they loved about their job. They get to know not only their coworkers but also the patients they care for every day. This helps them foster deeper connections with their patients and provide even better care.

Key takeaway: Hospital leadership can nurture a sense of community by encouraging strong relationships between staff and patients, providing opportunities for team bonding, and celebrating the unique connections that make rural communities special.

Consistency and continuity of care

Rural nurses value the ability to develop long-term relationships with their patients. “Continuity with coworkers and the providers. The ability to pair staff strengths in situations to make all involved in the care of a patient and their family the best it can be. Also, this allows for certain expectations to be completed making patient care faster and more effective,” one nurse explained. This continuity of care enhances patient outcomes and strengthens the bond between the nurse, the patient, and the community.

Key takeaway: Rural health care leaders can encourage nurses to stay long-term by investing in their professional and personal development. This can lead to higher-quality nurses and improved patient outcomes. Hospitals can support nurses by offering mentorship programs, continuing education, leadership pathways, and continuous recognition of a job well done.

Teamwork and trust

In rural hospitals, teamwork isn’t just a buzzword – it’s a necessity. Without extra backup staff or multiple departments to pull from in emergencies, nurses rely on each other to manage patient care effectively. One nurse said, “I love the sense of camaraderie that you develop with other staff members because in rural hospitals there is typically no backup from another floor or unit.”

Key takeaway: Hospital leaders can encourage a culture of trust and collaboration and ensure nurses have the tools they need to succeed, including training and open lines of communication with their leaders and coworkers.

What frustrates rural nurses

Inconsistent staffing resources

Despite the strong sense of community, many nurses expressed frustration over understaffing and lack of resources that rural hospitals face. One nurse noted, “The longer you stay the more they take advantage of you.” Another nurse shared, “We’re consistently short-staffed, and we don’t have the same opportunities or resources as larger hospitals.”

Key takeaway: Hospital leadership can address staffing challenges by offering competitive pay to permanent staff, improving work-life balance including flexible schedules, and investing in the resources nurses need to provide quality care. Flexible scheduling is a huge draw. In fact, one health system was able to bring back 25 percent of nurses who left by offering flexible opportunities, according to a recent study.

Limited learning and growth opportunities

Many nurses also expressed their frustration with a lack of educational and professional development opportunities in rural hospitals. One nurse noted the “lack of change,” while another voiced concerns about limited access to advanced training for managing complex patients.

Key takeaway: CEOs and CNOs can focus on creating opportunities for continuous learning, such as telehealth training, hands-on workshops, and specialized certifications that align with rural health care needs. Additionally, fostering a culture of mentorship and professional growth can keep nurses engaged and motivated.

Logistical and resource constraints

Rural health care comes with many unique challenges, such as delayed test results, transportation issues, and less access to higher-level care. One nurse described the frustrations of waiting for test results from other facilities, while another highlighted the challenges of arranging patient transfers due to limited ambulance availability.

Rural communities are faced with financial and staffing challenges that can limit their ability to complete tests internally. Despite these challenges, it’s important to recognize that rural communities are not to blame. Systemic limitations like a lack of resources, specialized medical services, or advanced diagnostic equipment are the result of broader health care infrastructure disparities that affect rural areas. Disparities are driven by geographic isolation and underfunding, which makes it difficult for even the most equipped rural hospitals to meet the needs of their communities.

Key takeaway: Leadership can alleviate frustrations by improving communication with larger facilities, streamlining transport protocols, and seeking out partnerships that offer telemedicine support or mobile diagnostic services.

Rural per diem and travel nursing: pros and cons

While some nurses love working as permanent staff, others choose to work as per diem or travel nurses. These roles can offer more flexibility but come with their own set of challenges.

Pros:

• Flexibility and pay: Many nurses appreciate the higher wages and the ability to control their schedules. “The pay is great, and there’s no call or extra expectations. I show up, do my job, and go home.”
• Diverse experience: Working at different facilities offers valuable learning opportunities. “I get to see how different hospitals operate, and it makes me a more adaptable and versatile nurse.”
  
  

Cons:

• Inconsistency: While flexibility is appealing, PRN nurses face challenges like unpredictable schedules, long commutes, and shift cancellations.
• Lack of belonging: Unlike permanent staff, travel nurses can feel disconnected from the hospital community. “You’re not part of the town or group, and it’s hard to prove yourself to the providers.”
  
  

What rural nurses want to see change

Rural nurses had clear suggestions for improving their job satisfaction:

• Increase pay for permanent staff: Nurses want hospitals to invest in competitive wages for long-term employees. Greater stability in nurse retention nationwide has come from higher wages. According to data from the Bureau of Labor Statistics, hospital-employed RNs saw an almost 22 percent increase in their annual mean wage from 2019 to 2023.
• Provide more training: Frequent education and training and hands-on learning opportunities are vital to keeping staff up to date and engaged.
• Improve staffing levels: Nurses want to see hospitals prioritize adequate staffing, especially on units like medical-surgical floors to prevent burnout.
• Modernized systems: Standardizing electronic medical records and providing clear, accessible expectations for charting and patient care can help alleviate frustration, especially for new staff or travel nurses.
  
  

The path forward: listening to nurses

Retaining and keeping nurses happy in rural hospitals comes down to understanding what they value and acting on their feedback. By cultivating a sense of community, offering competitive pay, flexible scheduling, and work-life balance, and providing opportunities for growth and development, hospital leaders can create an environment where nurses feel supported and motivated to stay. Rural hospitals face unique challenges, but by focusing on what makes rural health special — tight-knit teams and a deep connection to the community — rural health care leaders can ensure that their nurses thrive and stay at their hospitals. Doing the right things can result in lower RN vacancy rates, less staff burnout, lower recruitment costs, and higher patient satisfaction.

NRHA adapted the above piece from Cascade Health Services, a trusted NRHA partner, for publication within the Association’s Rural Health Voices blog.

About the author: As a Director at Cascade Health Services, Ian Yazbec specializes in providing per diem staffing solutions for rural, critical access, long-term acute care, and rehab hospitals across the U.S. With 10 years of health care and staffing experience, they lead initiatives to ensure high-quality service and workforce management tailored to the unique needs of rural hospitals. Their focus is on improving patient care by helping rural hospitals maintain adequate staffing levels with high quality nursing professionals.