“If Only Someone Had Told Me …”: Lessons From Rural Providers

According to the United States Department of Agriculture (USDA) Economic Research Service (ERS), rural and frontier America consists of approximately 80% of the US landmass and is inhabited by 50 million people (http://www.ers.usda.gov). Rural America is increasingly more culturally diverse with approximately 20% of rural residents indicating their heritage as Hispanic, African American, Native America/Alaska Native, Asian, or multi-race.1 Although rich with diversity, rural and frontier areas often have limited economic resources. Rural regions report limited economic growth, lower median income, and higher rates of poverty than their urban counterparts. These economic disparities are even greater in rural areas with concentrations of racial and ethnic minorities.2 Given the unique and complex features of rural America, many challenges arise in the provision of effective and ethical health care.3 One major challenge is related to geographic and travel barriers that rural residents and health care providers encounter.4–6 Due to these geographic challenges, some rural residents make trade-offs between their safe travel in inclement weather and accessing health care in a timely manner. Rural residents incur more expense to travel to regional centers to receive care that may not exist in their local community. Additionally, due to distance and access restrictions, rural residents with a chronic illness may not receive updated information regarding new treatment strategies.6 Residents and providers have limited access to specialized providers, consultants (ie, cardiologists, oncologists, psychiatrists), and additional resources due to the rural geography.7–10 Additional impediments to effective and ethical rural health care come in many forms including economic disparities,11,12 navigating multiple relationships,3,7,13,14 cultural and communication differences,15–18 and regularly encountering ethical dilemmas.18–20 Adding to the complexity of rural practice, providers are often working in demanding environments, with heavy caseloads, high patient acuity, and limited time for vacations.12,13,21 Over the last decade, efforts have attempted to address these issues through the development of various rurally tailored education and training programs designed to prepare health care providers for service in rural communities.22,23 Although a worthy endeavor, these efforts have been marginal in their success due to the very challenges experienced by rural health care systems, including complications in recruitment, retention, and training of rural health care professionals.22,24 Rural providers confront challenges related to too few continuing education opportunities25 and insufficient supervision, training, and preparation for the uniqueness of providing care in rural and remote settings.13,26 The difficulty of practicing in rural settings with limited training opportunities, or being ill-prepared for rural practice at the onset, inhibits retention and recruitment of a rural workforce.27–29 These factors result in high rates of depression, burnout, and turnover among rural providers.30 To develop and maintain a rural workforce and to avoid the pitfalls experienced by many rural practitioners and residents, it is vital to adequately train and prepare providers interested in rural health care. The intersection of rural living and health care challenges can create barriers to care that health care providers may not be trained to navigate, resulting in burnout and high turnover. The purpose of this study is to enhance knowledge and understanding of the preparatory needs of professionals embarking on careers in rural health care settings. More specifically, this qualitative study provides a comprehensive analysis of what experienced rural health care providers wish they had known prior to embarking on their own careers. Through the exploration of experienced rural providers’ knowledge and lessons learned, the ultimate aim of the study is to help inform future practitioners, educators, and policy makers in training, recruiting, and maintaining a rural workforce across multiple health care domains. Findings such as these are crucial in the development and maintenance of a sustainable rural workforce.