By: Michelle Wein
The struggle of rural health care facilities to recruit qualified individuals for employment is a well-dissected problem across the industry. Wages are often higher in urban areas – a November 2021 study from the Chartis Group reports that 42 percent of rural hospital respondents say that the number one reason for nurse staff departures in 2021 was more financially lucrative opportunities at another hospital. In that same survey, 98.5 percent of respondents said that they were experiencing a staffing shortage, and 96 percent of respondents identified nursing as the most difficult job to fill.
None of this is surprising – in addition to wages, post-secondary education institutions that train individuals for these jobs are often located in urban areas, making recruitment of new workers an easier task in cities and suburban areas compared to rural locations. The more surprising trend is that nursing turnover appears to be lower in rural areas. The Small and Rural Health Hospital and Policy Program, a part of the Michigan Health and Hospital Association (MHA), has a list of all rural hospitals located in the State of Michigan. Using this provided list, MHC Insight was able to define the entirety of the Upper Peninsula (UP) as rural area, and in comparison, used the tri-county metro Detroit area (Macomb, Wayne and Oakland) as a proxy urban area.
Using separations and employment data from EMSI (sourced from the Quarterly Workforce Indicators, and modeled to occupation level via staffing patterns), MHC Insight estimates turnover in the UP and the tri-county area for various healthcare occupations. As is shown in the tables below, turnover in Nursing occupations (Registered Nurses, Nurse Anesthetists, Nurse Midwives, Nurse Practitioners, Licensed Practical and Licensed Vocational Nurses) in the tri-county region is significantly higher than the in the UP.
Urban 3 County Turnover | 2017 | 2018 | 2019 | 2020 | 2021 |
Registered Nurses | 16% | 22% | 16% | 34% | 34% |
Nurse Anesthetists | 20% | 16% | 16% | 33% | 30% |
Nurse Midwives | 24% | 27% | 20% | 36% | 34% |
Nurse Practitioners | 20% | 21% | 21% | 32% | 32% |
Licensed Practical and Licensed Vocational Nurses | 39% | 50% | 48% | 57% | 58% |
Total | 18% | 25% | 20% | 36% | 37% |
Rural UP Turnover | 2017 | 2018 | 2019 | 2020 | 2021 |
Registered Nurses | 13% | 14% | 13% | 21% | 21% |
Nurse Anesthetists | 32% | Insufficient Data | 27% | 20% | 20% |
Nurse Midwives | Insufficient Data | Insufficient Data | Insufficient Data | Insufficient Data | Insufficient Data |
Nurse Practitioners | 28% | 15% | 22% | 21% | 21% |
Licensed Practical and Licensed Vocational Nurses | 67% | 45% | 38% | 37% | 37% |
Total | 27% | 21% | 19% | 24% | 24% |
In 2021, total nursing turnover was 13 percentage points higher in the tri-county area than in the UP. Total nursing turnover was also higher in the tri-county area in 2020, the first year of the COVID-19 pandemic. Interestingly, the preceding three years show turnover in the two areas to be much closer in estimation, and in fact, in 2017, to be nine percentage points higher in the UP than in the tri-county area, and nearly equal in 2019.
Without more rigorous statistical analysis, MHC Insight cannot definitively state that the COVID-19 pandemic in 2020 dramatically increased the turnover differential between rural areas and urban areas (and indeed, these are just two proxy locations for both urban and rural in the State of Michigan). However, it is reasonable to infer that the pandemic was a significant contributing factor to the increase in the turnover differential. Indeed, between 2019 and 2020, the metro Detroit area saw nursing turnover increase by 16 percentage points, while in the UP, turnover only increased by five percentage points – indicating that the pandemic may have played a bigger role in turnover in urban areas than in rural areas.
Potential overall explanations for differing turnover trends in rural versus urban areas include more opportunities for transfer or new job opportunities in urban areas, or higher wage growth in urban areas that encourages turnover. For example, in the UP, the average wage for nurses in 2021 was $31.48, while in the metro Detroit area the average wage was $37.95. There could also be non-wage related reasons (e.g. family, lifestyle) nurses in rural areas remain in their jobs.
Reducing turnover in rural and urban areas going forward will be critical to strengthening the health care workforce. Appreciating the different reasons rural versus urban nurses decide to stay in or leave jobs is important since the data show it does not necessarily come down to money, even when a pandemic hits.