Addressing the shortage of registered nurses in rural America
Across the United States, rural communities face persistent challenges in accessing healthcare. These regions are home to approximately 20% of the U.S. population, including more than 2.7 million veterans receiving care through the Department of Veterans Affairs, yet they continue to experience significant shortages of health professionals. Among the most critical gaps is the shortage of registered nurses (RNs), who are essential providers of patient care, chronic disease management and care coordination in primary care settings.
Despite being the largest health profession in the country, only 16% of RNs practice in rural areas. This disproportionately low workforce results in delayed care, poorer health outcomes and added stress on rural health systems.
To better understand how to build and sustain the rural nursing workforce, we conducted a scoping review of recruitment and retention programs across the U.S, which recently was published in Medical Care.
What we found
The literature search identified 1,179 unique articles; however, only 60 articles met the inclusion criteria, and an additional 42 programs were identified from the gray literature, for a total of 102 unique programs across the country. Each aimed to support rural nurses, from high school students considering nursing careers to experienced RNs already practicing in rural communities.
Key findings include:
- Most programs focus on education (n = 85), where n indicates the number of programs in that category. Educational efforts included nursing residencies and pathways for rural students to enter nursing school. These educational opportunities help expose future nurses to rural practice environments early in their training.
- Few programs take a multipronged approach. Only 22 programs combined two or more strategies to address the complex barriers nurses face.
- Financial incentives are underutilized. While scholarships (n = 15) and loan repayment programs (n = 17) exist, long-term compensation improvements were rare (n = 6).
- Minimal policy or regulatory efforts (n = 4) were identified, pointing to a major need for support at the state and federal levels to grow the workforce.
Importantly, many strategies targeted nurses who already are practicing, reflecting an understanding that retaining experienced clinicians can be just as impactful as recruiting new ones.
Why this matters for veterans and rural communities
Rural residents are often older, have higher rates of chronic illness and must travel farther to access care. For rural veterans, many living with service-connected conditions, these challenges are further amplified.
Strengthening the rural nursing workforce directly impacts:
- Continuity of care.
- Care quality and safety.
- Physician retention in rural systems.
- Health equity for underserved populations.
The Veterans Health Administration, as the country’s largest integrated health system with a strong rural footprint, is uniquely positioned to lead innovation in this space.
Looking ahead
This project offers a national snapshot of what is being done, and what isn’t, to support the nurses’ rural communities that depend on them. It also highlights a critical next step: evaluating which of these strategies actually work. Without data on program outcomes, rural health leaders lack clear guidance on how best to invest limited resources. As demand for nurses continues to grow, the need for evidence-based, sustainable workforce development strategies has never been greater.
By Dr. Kelley Arredondo, assistant professor, Baylor College of Medicine; investigator, Center for Innovations in Quality, Effectiveness and Safety at Michael E. DeBakey Medical Center; assistant director, Center for Professionalism
