According to the U.S. Census Bureau, one in five Americans lives in a rural area. Many live in healthcare “deserts,” where access to healthcare and providers is in high demand but short supply.
Rural Americans are more likely to die from preventable conditions like heart disease, cancer, and stroke. Many also have a higher rate of suicide, unintentional injury-related death, and opioid overdose than their urban counterparts, according to the Centers for Disease Control and Prevention (CDC).
Q&A With a Rural Nurse Practitioner
Angela Quilty, RN, FNP-BC, has been a nurse for more than 20 years and a family nurse practitioner (FNP) for over seven years. She has a background in ICU, ER, hospice, and interventional radiology. She currently works with Wilderness Medical Staffing as a locum tenens family practice provider in rural Montana.
Quilty was interested in joining Wilderness Medical Staffing for a few years as a registered nurse. Then again after she became a FNP, and finally, when her kids were in college.
What attracted Quilty to the nurse practitioner-owned staffing company was it allowed her to travel; she was always interested in traveling around the United States. But most importantly, the staffing agency places medical providers in rural and remote communities.
In 2019, Quilty accepted a position as a FNP to care for patients in rural Montana on the Fort Peck Reservation, home to the Assiniboine and Sioux Tribes. Although faced with the challenges of being a solo provider and learning a new culture, this is the fourth time Quilty renewed her assignment, and she doesn’t see herself leaving yet.
Learn more about Quilty’s experience as a rural NP, what a rural NP does, what challenges they face, how to become one, and how much rural NPs make.
What Does a Rural Nurse Practitioner Do?
Quilty originally planned to work in Alaska, but the assignment didn’t fit her travel needs. She wasn’t leaving without her husband and two dogs. So instead, after a four-week application process, Quilty packed up her family and arrived in Montana on the Fort Peck Reservation, with a population of over 9,000. The town Quilty was assigned to has a little over 400 residents.
A rural nurse practitioner has many roles. “It’s a little bit of critical care, a lot of mental health, a lot of family practice pediatrics. It is everything,” Quilty points out.
Their broad scope allows FNPs to see patients of all ages. Quilty is assigned to a school-based clinic caring for students K-12. But, because she is the only practitioner in her clinic, Quilty also provides adult care. “I treat the teachers and their spouses because we have a lot of people come out on contract to teach. They come from all over the United States,” she says.
A rural NP has many responsibilities. Since the majority of Quilty’s patients are school-aged, she treats many acute illnesses like:
- Strep throat
- Staph infections
But mental health has almost overtaken the medical diagnosis, Quilty says. The CDC reports children in rural areas with mental, behavioral and developmental health conditions experience more community and family challenges than urban children facing the same conditions. “We have a lot of overwhelming issues with mental health [like] anxiety, depression, and suicidal [thoughts],” she explains.
Listen to how Quilty combats the mental health crisis in her community through telehealth services.
“During the height of Covid, It was 50-50 between in-person and telehealth, and
we still do, really. I probably do like 5 or 10 a week [of telehealth services], depending if we have providers in the other towns, but we do have telehealth providers. We have pediatric specialists that are based out in a town called Bozeman that the hospital or the companies have been contracted with a psychiatrist, a mental health therapist, a pediatric cardiologist, and pediatric neurologists to help see the patients, and so we’re starting to ramp up the referrals and do more telehealth visits on that end for the kids here.”
Quilty also works closely with pharmacists in the community if she has any treatment-related questions. The collaboration among providers and pharmacists improves access to care and is another way she provides services to her patients.
What Challenges Do Rural NPs Face?
Some rural areas have challenges simply because of geographical location — many are hours away from urban cities. The nearest airport from the reservation is a four-hour drive. Quilty jokes that making a trip to Costco and Walmart, which is 2 hours away, is an event. “We bring a cooler with us, and everything is in it,” she says.
Transportation is a significant obstacle for her patients. As a result, Quilty’s clinic provides many services so her patients don’t have to travel to the next town or nearest hospital. Services include:
- Women’s health
- Point-of-care testing like glucose or cholesterol checks
- Health screening
- Wellness checks
- Physical exams
- Acute care
Other challenges include minimal internet service outside the clinic, using a fax machine for prescriptions, and adjusting to the cultural change.
Listen to Quilty describe coming to the reservation.
“I didn’t know what to expect when I came out here. And then of the population. You know they’ve had some positive experiences. They’ve had some negative experiences with people from other cultures coming out here, so trying to, you know, make build up the trust, make the community realize that I’m here to help and I’m just like everyone else, you know, we all are just like everybody else. We have our mental health issues, drug issues in every town and city in the United States and trying to portray that empathetically.”
Quilty found it was a hard adjustment living on the reservation. Coming from New York and Florida, where she’s lived and worked with a diverse population, she suddenly became the minority on the reservation. At first, many residents didn’t trust her.
“They don’t trust new people, which is understandable because, I mean, a lot of times people come in and come out,” Quilty explains.
Many healthcare providers take assignments through agencies that will pay off their student loans under a student loan forgiveness program. Once the provider’s assignment is complete, the providers leave the assigned area. This can be very difficult for the community, especially the pediatric population, who have built relationships with their providers.
Another challenge Quilty has encountered is a high case of drug use in the community. She describes methamphetamine and fentanyl as “everywhere.” Many students’ parents are nonexistent due to drug use or overdoses. “We have some households where the grandmother has 17 kids in the house. They might not all be her grandkids, but they are like her sister’s grandkids,” Quilty says.
This is no coincidence. According to the Department of Justice, methamphetamine use disproportionally affects American Indians. The Mexican drug cartel often targets these communities because of complex drug laws and historically understaffed and underfunded tribal government police. Tribal leaders and government officials are creating plans to combat drug sales and abuse.
How to Become a Rural NP
To become a rural NP, you must have a few years of nursing and nurse practitioner experience. The requirements for Wilderness Medical Staffing are:
- Master’s in nursing degree
- At least three years of NP clinical experience
- Advanced Cardiac Life Support (ACLS) certification
- Advanced Trauma Life Support (ATLS) certification
- Basic Life Support (BLS) certification
- Pediatric Advanced Life Support (PALS) certification
Due to the lack of resources in rural areas and you being the sole provider, it is very important you know what you’re doing clinically. Although being autonomous can be great, it also can have a downside, Quilty says.
“You don’t have the hallway consults and your coworkers there. There are no resources like radiology, labs, X-ray,” Quilty points out. There is also no secretary and or ancillary staff.
Quilty has been the sole provider for a year, and another nurse was recently hired. But, due to the nursing shortage, it has been difficult to find staff.
But Quilty doesn’t want to discourage nurse practitioners. Being a family nurse practitioner provider in a rural setting is something she thinks everyone should experience.
“You really get to know the community and your patients and the trust that you build up with them. You get to see your follow through and the effect that you’re making on the community,” Quilty points out.
It can be emotionally overwhelming because you live and work in the community, Quilty says. “You have to develop how to take care of yourself [and] how to separate when you leave for the day…it’s not as easy as I thought it would be.”
Listen to what Quilty does for self-care.
“My husband’s out here, so he gets to listen to me, and he tries to give me advice for a non-medical husband, you know [we do] outdoor activities. We just try to go out and do whatever we can and Montana’s a gorgeous state. It’s just got like this wild, untouched atmosphere that I haven’t experienced in Florida or like really, in New York City like it’s New York City’s attitude, and stuff, but in outdoorsy stuff. So you know, we just said, okay, it gets super cold here, and it snows, and let’s see what we can do outdoors. So you know we started doing stuff, I never thought I’d do. I joined a Bowling League, met some nice people. I didn’t think I’d ever joined Bowling League.”
How Much Do Rural NPs Make?
According to the Bureau of Labor Statistics, the average annual salary for NPs was $124,680 in May 2022. Recruiting healthcare providers into rural health is difficult, so a rural NP’s salary may be higher than NPs working in urban settings. NPs can also apply for tuition reimbursement through rural health nursing programs.
Quilty’s contract is a locum tenens 1099 contract. She gets paid hourly through the agency.
“Locum tenens is Latin for saving a place. It’s just like the nurse travel companies. But for nurse practitioners, PAs, and doctors, [the agencies] offer any kind of assignment, short or long,” Quilty explains.
Usually, housing is included in the contract, and you receive a stipend. The contract can be anywhere from a few days to months. Quilty points out it’s always important to negotiate your travel assignment, especially if you have the extra experience needed for the role.
Quilty only lives a few blocks from her clinic, which makes her accessible to her patients on and off the clock. When she isn’t treating patients, a hobby Quilty and her husband picked up is rescuing stray dogs and rehoming them. The community calls them “rez dogs,” and she says hundreds are on the streets.
“So that was one of the harder things, too. I was like, why are these dogs walking around? They’re gonna freeze to death in the snow,” Quilty says.
She and her husband built dog houses in their driveway and garage. They have rehomed 24 dogs and plan to continue to find homes for others.
Although being a rural health NP can be hard, Quilty says you aren’t defined and pigeonholed into one area. “You have to just go with the flow. Go with everything, and be prepared for whatever walks through the door.”