Photo of three nurses conferring at a vaccine clinic
Audrey Snyder oversees nursing students at a vaccine clinic. (Photo courtesy of Snyder.)

Editor’s Note: This interview first appeared in Path Finders, an email newsletter from the Daily Yonder. Each week, Path Finders features a Q&A with a rural thinker, creator, or doer. Like what you see here? You can join the mailing list at the bottom of this article and receive more conversations like this in your inbox each week.

Last week, the Daily Yonder published an article about the costs of well-paid travel nursing positions on rural healthcare systems. From staffing shortages, to hospital closures, to aging rural populations, the Covid-19 pandemic has clearly exposed and exacerbated some long standing problems within the incentive structures of healthcare work. I spoke with Audrey Snyder, who is the Associate Dean for Experiential Learning at the University of North Carolina Greensboro’s School of Nursing, and former president of the national Rural Nurse Organization—two roles which share the explicit goal of problem-solving in rural healthcare.

Enjoy our conversation about travel nursing, vaccine mandates, and toxic positivity, below.

Olivia Weeks, The Daily Yonder: What are the incentives for nurses to work at rural hospitals right now? What’s the staffing situation at rural hospitals generally?

Audrey Snyder: There are not a lot of incentives for nurses working at rural hospitals right now. Hospitals are trying to find small ways to express their gratitude to nurses. Nurses in general have a positive feeling when they know they are caring for their own community. Working in a small community can come with its own challenges since word of a person being ill can travel fast and nurses must maintain confidentiality even when someone may ask about a patient when they see the nurse in the community. Staffing is globally short though and nurses are overworked and feeling the strain of the Covid-19 pandemic as it wears on.  We have seen hospitals decreases their open bed numbers related to a lack of staffing. With recent increased cases with the delta variant surge some rural facilities have had difficulty transferring patients to a higher level of care because those facilities are also strained. In 2020 during the pandemic there were 19 rural hospital closures and a few more have closed this year. We worry about future closures and the impact this will have on access to care and the health of rural community. Rural residents will have to travel further to access care.

DY: To what extent are rural nursing shortages due to discrete issues like vaccine mandates and high-paying travel nursing positions, and to what extent are they the result of broader structural trends in rural life and economics?

AS: In general there is a smaller population of people living in rural areas and this means there are less people from rural communities going into healthcare professions, including nursing. We were in a nursing shortage prior to the pandemic. The pandemic just shed light on the challenge of rural facilities maintaining staff. Urban centers have been pulling nurses to higher paying travel positions for a while. With the pandemic, this phenomenon has increased as urban areas who have had large Covid outbreaks are paying travel companies to staff their facilities. There are some rural areas with travel nurses also, but most rural hospitals cannot afford the high cost of travelers. When there are traveling nurses in any facility, nurses on the payroll may get upset when they find out the salary the traveling nurses are making, which is often higher than the established facility nurse’s salary.

Rural areas have lower Covid-19 vaccination rates, and this may extend to healthcare providers as well. With the federal mandate for health care professionals to be vaccinated for Covid-19 hospitals may lose more nurses if the nurses refuse to be vaccinated.

Many rural nurses’ families are embedded in the rural community. Their family may farm for example. Taking a job at a distance could significantly impact home life and present challenges with being on the road daily. For some younger nurses they may see travel nursing as a means to see a distant part of the country and a way to pay off debt.

DY: How do you attempt to encourage rural nursing at UNCG?

AS: Many of our nursing students come from rural areas. At UNCG we have clinical agreements for nursing students to train in many rural facilitates.  One of our community health rotations is in a rural elementary school focusing not just on school health but community health. Health disparities are amplified in rural communities, and this provides for teachable moments with nursing students. We know that exposure to a rural environment while nursing students are in school can increase the likelihood that they will look at a rural community for work. 

We have collaborations with rural community colleges in the area to offer Registered Nurse to BSN programs. Many nurses in rural areas train in Associate Degree programs locally at community colleges, but many hospitals want nurses who are trained at a bachelor’s level, especially if they are a Magnet hospital. The hospital may hire a nurse with an associate’s degree with an agreement that the nurse will obtain a bachelor’s degree within a certain time frame. Attending a program close to their community decreases travel times for these nurses. 

UNCG was awarded a four-year federal grant in July to help train nurse practitioners to work in rural and medically underserved communities. This grant is enhancing our doctorate of nursing practice program and providing support to 16 of our Adult Gerontology Primary Care Nurse Practitioner students. We also have nurse anesthesia students in clinical rotations in rural hospitals. Our hope is that exposure to rural communities, smaller rural hospitals and rural life may entice graduates to work in these areas.

DY: What purpose is served by the Rural Nurse Organization and organizations like it?

AS: The Rural Nurse Organization (RNO) serves as a voice for rural nurses, promotes awareness of rural health concerns, provides education on current topics for nurses and offers opportunities for collaboration on practice issues, research, leadership, and education. The RNO offer a conference every other year where nurses can come together to address all aspects of rural nursing. The Rural Nurse Organization is part of the Council of Public Health Nursing Organizations and in this position the organization advocates for local, state and national policies that improve public health, promoting equitable healthcare for all. 

Photo of Audrey Snyder
Audrey Snyder is the Associate Dean for Experiential Learning at the University of North Carolina Greensboro’s School of Nursing. (Photo courtesy of Snyder.)

DY: All credit to my wonderful nurse friend Sunny for the term, but I’m wondering if you have thoughts on ‘toxic positivity,’ or the compulsion to maintain a positive attitude even in objectively hard times. Do you experience that mindset as a coping mechanism particular to nursing work, especially throughout the pandemic?

AS: I love Sunny’s term “toxic positivity.” I believe many nurses and leaders embrace this attitude in hard times, especially during the global Covid-19 pandemic. We are living in unprecedented times. Nurses are used to dealing with difficult situations. Often, they make comparisons looking for the bright side. A nurse may be exhausted and may have lost 2-3 ICU patients in a day due to Covid but may say, “I am still alive,” grasping the positive in the midst of a difficult negative situation. In rural areas persons are dying at twice the rate of those in urban areas. Rural nurses are seeing members of their immediate community die. 

Having a positive attitude can help nurses cope, but the reality is undeniably bleak. Repetitive emotional trauma is really impacting nurses and their families. Early in the pandemic many people who died were vulnerable older adults prior to the vaccine being available. Now it is mostly younger, unvaccinated adults. Many of these deaths are considered preventable if the person would have accepted the vaccine. It is senseless deaths of mostly younger persons that nurses are coping with now. A positive of this pandemic is the recognition of the daily stressors and mental health impact on nurses and the creation of resiliency programs by employers and organizations, like the Well-being Initiative the American Nurses Association has developed. The program is available to all nurses, not just members.

This interview first appeared in Path Finders, a weekly email newsletter from the Daily Yonder. Each Monday, Path Finders features a Q&A with a rural thinker, creator, or doer. Join the mailing list today, to have these illuminating conversations delivered straight to your inbox.

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