Nurse helping elderly man

Small Towns, Big Opportunities for Nurses and Nurse Practitioners

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I recently had the privilege and pleasure of seeing John Mellencamp perform live at Wolf Trap National Park for the Performing Arts in Virginia. It was a warm summer night, so I kicked back on a blanket on the lawn of the outdoor theater and listened. I was looking up at the stars when Mellencamp starting singing, “Small Town.” The lyrics inspired some reminiscing about my own origins in a small town.

I left Cortland, NY (population <20,000) without any thought of becoming a nurse or a midwife. At age 17, I wandered off without clear direction and roamed through Upstate New York and New England. Along the way, and by grace of the birth goddess (or just by coincidence), I happened across an unexpected introduction to contemporary midwifery. I have been on that path ever since.

Mellencamp continued singing and I continued thinking, my mind wandering to the origins of nurse-midwifery and advanced nursing practice. NP history dates back to the 1960s, and midwifery long before that. Both grew out of the foundation of the Frontier Nursing Service (FNS), established by Mary Breckenridge in the small town of Hyden, KY, in the mid-1920s,

Working in poor, rural areas of Appalachia, FNS nurses cared for the people of Appalachia, traveling to places where there was no doctor, and where no doctor wanted to go. Breckenridge, educated as a nurse in the U.S., as a midwife in England, and in public health in NYC, collected records of the services of FNS nurses. Her statistics, illustrating improved outcomes and reduced mortality rates, did not go unnoticed.

Looking at current outcome and patient satisfaction scores, NPs and CNMs consistently continue to demonstrate clinical outcomes and patient satisfaction scores that are at least as good as those of physicians. Doctors, particularly specialists, continue to shy away from rural areas and aggregate in larger cities. Per population, there are fewer than half the number of physicians available in rural areas compared to urban areas, with the most rural populations having about 1/6 the number of physicians per capita as urban populations.

The National Conference of State Legislators (NCSL) predicts the shortage of rural health care providers to grow. NCSL reports a current need for “thousands” of additional primary care providers (PCPs), and predicts that “tens of thousands” of additional PCPs will be needed to meet the needs of a growing rural population. Rural primary care is a niche just waiting to be filled by NPs.

I spoke with David Wolfe, owner of NP Now, an NP recruiting firm. NP Now places nurse practitioners in permanent positions in both urban and rural settings, with 80% of his requests for NP’s coming from rural areas. He said that “client demand [for NP’s] is growing…as doctors are harder to find, and many of the current ones are retiring in the next 5-10 years.” Currently, I was told, NPs with roots in rural areas are filling the primary care gap, but with the predicted shortage of primary care providers, “local” NP’s will not be able to meet the demand.

Now is a great time to make that transition from RN to NP. You are wanted, you are needed…and the role now carries an unprecedented degree of autonomy and respect. If you’ve ever dreamed of having your own little practice in a place where you truly get to know your patients, a rural setting could be ideal for you. If the only thing holding you back is the cost of education, consider a couple of things. The National Health Services Corp designates many rural areas for loan repayment. The salaries for NP’s in rural areas tend to be similar to the salaries of those working in urban areas, but the cost of living in rural areas is much lower.

Then think beyond the attractions of loan repayment and a competitive salary. In a small town, the pace of life is slower, the commute is shorter, and the sense of community and support can be stronger. The appeal of small town life continues to tug at my heart and soul, but I’ve ultimately learned that it isn’t for me, at least not for right now. Who knows though? Maybe you can go and have yourself a ball in a small town.

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About the Author

Carina Ryder, MS, CNM, NCMP is a midwife currently in practice in Washington, DC. She received her BSN and MS from Columbia University School of Nursing in the mid-1990s. Carina provides gynecologic and obstetric care to women from adolescence through menopause. She is a member of the American College of Nurse-Midwives, the American Society for Colposcopy and Cervical Pathology, the Association of Reproductive Health Professionals, the North American Menopause Society and the International Society for the Study of Women’s Sexual Health.