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Nurse retention is better in rural communities with a hospital, study reveals

Research finds nurses were more likely to leave a large health care system in areas without an affiliated hospital, pointing to a potential benefit of hospitals in rural areas
nurses walk in hallway, away from viewer

Rural areas that do not have a hospital in the community experience increased nurse turnover, according to a new study co-authored by Elena Andreyeva, PhD, assistant professor at the Texas A&M University School of Public Health. The paper, “Nursing Turnover in a Large, Rural Health System,” was recently published in The Journal of Rural Health.

This study conducted by Andreyeva and researchers from the University of Pennsylvania and Stanford Health focused on a large health care system with 27 affiliated hospitals in South Dakota, North Dakota and Minnesota. The health care system provided researchers with data from 7,634 registered nurses who were employed by the system between January 2016 and December 2017. Approximately 1,765 of these nurses worked in rural communities that were served by the system’s health care facilities.

The research team’s most important finding was that the presence of a hospital in a community serves as the linchpin supporting nurse retention in these rural areas. Communities without an affiliate hospital had a 27 percent nursing turnover rate during the study’s two-year period. In comparison, the turnover rate was approximately 18 percent in rural communities that had an affiliated acute hospital or a critical access hospital.

“What we found is that if a nurse worked in a rural area that did not have a hospital, they were much more likely to leave the health care system,” Andreyeva said.

This study is important because of the increasing number of closures of rural hospitals in the United States. According to the Center for Healthcare Quality and Payment Reform, more than 130 rural hospitals have been shuttered over the past decade, while an additional 600 rural hospitals are currently at risk of closure.

“If you think of a hospital serving as an anchor for all of the health care resources and facilities in the particular area, if that anchor is gone, there is a ripple effect across other health care facilities,” Andreyeva said. “The hospital’s loss makes things worse for the geographic area that is affected. Other health care providers who might have been impacted by the closure are much more likely to leave the area once the hospital is gone.”

This latest study also extends Andreyeva’s previous research on rural hospital closures. “This tells us that if the hospital is gone, that might lead to adverse health outcomes,” she said. “If you have a health emergency and there is not a hospital around, patients are much more likely to experience adverse health outcomes, including mortality.”

The researchers also analyzed the health care system’s overall nurse demographic data. The team found that overall, 19 percent of the health care system’s nurses left their position during the two-year period. North Dakota’s facilities had the highest turnover rate (22.2 percent), compared to Minnesota (17.3 percent) and South Dakota (15.8 percent). Urban areas had a 19.3 percent turnover rate, which was slightly higher than rural areas (18 percent).

Gender and age also were factors in turnover. Male nurses had higher turnover rates than female nurses. Additionally, nurses who were age 30 or younger as well as those above the age of 60 were the most likely to leave their jobs.

Tenure also contributed to retention. Nurses who had been with the system for 10 years had a lower turnover rate (12 percent) compared to nurses who had been employed with the system for two years (21 percent).

This study does not consider the effect of the COVID-19 pandemic on nursing turnover. “It would be interesting to look at it with newer data now as turnover rates have been increasing because of nursing fatigue and the idea that nurses can make more money being a travel nurse than being an in-house nurse,” Andreyeva said.

Media contact: Dee Dee Grays,, 979.436.0611

Dorian Martin

SPH - Director of Communications and Alumni Affairs

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