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Qualitative Perceptions of Opportunity and Job Qualities in Rural Health Care Work 

 
Rayna Amber Sage, PhD 1  

 

1 Clinical Assistant Professor, Washington State University, rsage@wsu.edu  

 

Abstract  

With rural health care worker shortages projected to only worsen in the coming decades, many 

rural communities are attempting to institute local training and education in hopes of retaining a 

stable local direct care workforce. This study uses qualitative methods to explore how local 

health care training, education, and employment are perceived by rural residents in one isolated 

community where most of the local jobs have transitioned from manufacturing and natural 

resource extraction to health care and education. Based on 60 in-depth, semi-structured 

interviews and 40 hours of participant observation primarily as a volunteer in a long-term care 

facility, I find that perceptions about the opportunities in health care that remain in 

“Independence Creek, Washington” are complex and divergent. The majority of participants 

speak positively of the local trainings for nursing assistants and the innovative on-site two-year 

nursing program and argue that these opportunities, seen as either a stepping stone for college-

bound young adults or a pathway to decent employment for place-bound individuals, are much 

needed. Perceptions of pay for nurses are also favorable. Perceptions of pay for nursing assistants 

are more mixed. Respondents consider it better than other service work, but also not a livable 

wage. Job security is perceived as a big plus, as respondents describe the ability to “get a job 

anywhere” as a nurse or nursing assistant. However, job stability (having regular hours and work 

place stability) are not described as strong qualities of working in rural health care. Despite 



	
  

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issues with some negative perceptions of rural health care work, this study demonstrates a 

continuing need for more local training as we work towards higher quality working conditions 

and compensation.  

Keywords:  Nursing assistant training, Nursing education, Pay, Job stability, Job security    

Qualitative Perceptions of Opportunity and Job Qualities in Rural Health Care Work 

For decades, the Department of Labor has been tracking and predicting the growing need 

for all types of health care workers, including registered nurses (RNs) and direct care workers 

(DCWs) such as certified nursing assistants (CNAs) and nursing assistant-certified (NACs) (U.S. 

Department of Labor’s Education and Training Administration, 2010). These terms are used 

interchangeably in this paper. In Washington State, demand for nurses is expected to grow from 

about 35,000 to 60,000 in 2020 (Skillman. Andrilla, & Hart, 2007). However, with current 

degree programs and student slots, the projected supply of nurses is actually expected to drop to 

near 30,000 in 2020. This need is even more critical in rural areas of the United States, which are 

home to about 65% of all Health Professionals Shortage Areas (National Advisory Committee on 

Rural Health and Human Services, 2011). For rural residents the pursuit of college, including 

nursing education, almost always means leaving their hometowns (McDonough, Gildersleeve, & 

Jarsky, 2010; Molinari, 2001). While community colleges have been partnering with rural 

communities and local institutions for some time, little is known about how increasing local 

educational and training opportunities is perceived by the individuals who live in the affected 

communities. This study builds on existing literature regarding access to training and education 

in rural places and the nature of jobs in rural health care to explore how residents in one rural 

remote Pacific Northwest community perceive and integrate opportunities in health care into 

their own discourses regarding education and work. More specifically, this study examines how 



	
  

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local training and educational opportunities in health care are perceived and how individuals 

describe the pay, stability, and security of health care employment. 

Theory and Literature Review 

For rural people, the intersection of educational opportunities and the labor market plays an 

important role in making decisions about employment and career choices. Utilizing a grounded 

theory approach (Glaser & Strauss, 1967; Wuest, 2012), this project focuses on relevant patterns 

of beliefs about education and employment in health care to illuminate perspectives of direct care 

workers who occupy a position of lower privilege in the overall health care system compared to 

others in health care. To follow is a brief summary of what is currently known about rural 

educational opportunities, the changing rural economic landscape as it relates to opportunities in 

health care and what makes some jobs more attractive than others. This literature provides a 

background for understanding how the rural context is currently understood and how perceptions 

of opportunities in rural health care might be constructed by those in or considering the field. 

Access to Post-Secondary Training and Education 

Individuals living in rural communities have significantly less access to local post-

secondary educational opportunities than those living in urban or suburban areas (Gibbs, 1998; 

McDonough et al., 2010). This lack of local opportunity, coupled with more pervasive and long-

lasting poverty (Tickamyer & Duncan, 1990; U.S. Department of Agriculture/Economic 

Research Service, 2010) helps explain the large gap in college attendance and completion that 

exists between rural and nonrural young adults (Gibbs, 1998; Provasnik et al., 2007). Previous 

research suggests that a community’s proximity to urban centers and educational institutions 

influences the out-migration of young adults through the variation in access to education and 

employment opportunities within commuting distance (Gibbs, 1998; McDonough et al., 2010).  



	
  

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Community colleges across the United States have recognized this problem and many have 

taken steps in an attempt to increase access to education for rural individuals (Benson et al., 

2008; Eller et al., 1998; Jaeger, Dunstan, & Dixon, 2015). Since the early 1990s, community 

colleges have stepped up their efforts to reach potential students in economically distressed rural 

communities by investing in branch campuses, extended campus centers, and/or collaborating 

with other local institutions to provide on-site training and credentialing that met the 

communities labor market shortages in fields such education and health care (Baldwin, 2001; 

Holly, 2009; Proffit, Sale, Alexander, & Andrews, 2004; Rubin, 2001; Torres & Viterito, 2008). 

For local residents, these new opportunities meant that for some communities, out-migration was 

not the only way to get an education. However, little is known about the impacts of these 

changes on communities, families, and individuals. Some youth and young adults cannot or do 

not wish to leave their rural communities. For these individuals, education and training 

opportunities may be one of the primary ways to stay and be economically secure, although 

much of the success of retraining in rural places may depend upon what types of jobs are left for 

adults to fill and how those jobs are perceived. 

Health Care Work in Rural America: Good Jobs and Bad Jobs 

To better understand how local trainings may be perceived and perhaps utilized, it is useful 

to explore the types of jobs available in rural health care and how they can be assessed in terms 

of job quality. In a national assessment of in-migration at the county-level, Johnson (2006) found 

that rural communities experiencing the most growth were those where “retirement, service, and 

recreation” (p. 16) dominated the local economy. For these counties, the impact of in-migration 

of older and retiring adults changes the demands for services, especially around health care. The 

growing demand for health care workers has been accompanied by a marked decrease in jobs 



	
  

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available in other industrial sectors, especially those mostly occupied by men in rural 

manufacturing, resource extraction, and farming primarily due to technological advances 

(reducing need for manual labor), changes in industry and trade regulations, and shifting demand 

for materials produced through natural resource extraction (Flora et al., 1992; Morris & Western, 

1999). These economic shifts were most notable in the 1990s and have remained fairly stable 

since. Despite the increased demand for health care workers, there is a growing problem of 

recruiting and retaining RNs and DCWs in rural areas which appears to be, among other factors,  

the result of decreased interest in caretaking and nursing as a profession and job dissatisfaction 

(Aiken, Clarke, Sloane, Sochalski, & Silber, 2002; Roberge, 2012).  

Unfortunately, decreasing interest and job satisfaction are partially related to the fact that 

many health care occupations are what Mitnik and Zeidenberg (2007) would consider bad jobs. 

To distinguish between bad and good jobs, researchers look at a number of factors. First, to be a 

good job in the United States, the job must pay a decent wage (Mitnik & Zeidenberg, 2007). 

Mitnik and Zeidenberg (2007) suggest that a good wage is one in which a single full-time earner 

can support a family of four at higher than 150% of the poverty threshold. In a foundational 

study of rural families and labor, Nelson and Smith (1999) found job stability and character of 

the workplace are also important in identifying a job as bad or good. According to these authors, 

good jobs are those which are full-time and year round. In turn, bad jobs are those which are 

temporary, part-time, and/or seasonal. Good jobs are also characterized by having a regular 

schedule which does not vary from day to day or week to week. Additionally, workplace 

characteristics which would imply a good job include benefits and overall workplace stability 

(few layoffs, little concern about financial stability of the company). Finally, good jobs provide 



	
  

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opportunities for advancement through increased access, skills-training, and education (Mitnik & 

Zeidenberg, 2007).  

By these standards, many of the jobs in the health care field, especially in skilled-nursing 

facilities and home health care, might be considered bad jobs. Although the structure of the 

health care industry and its dependence on insurance companies and very limited government 

monies makes it difficult for these types of jobs to move into the status of good jobs, some 

facilities are attempting to address issues related to the negative qualities of jobs in health care 

through increased access to training and education which may make upward mobility more 

possible than in the past. Unfortunately, the structure of direct care work in long-term care 

facilities and in home health care is such that there is a greater need for staff at the bottom of the 

staffing hierarchy (who provide the direct care of residents and patients) than at the top (Mitnik 

& Zeidenberg, 2007). Nonetheless, according to this same study, hospitals may actually be 

places where upward mobility is possible with increased access, training, and education, because 

of the more balanced distribution of bad and good jobs (although the majority of jobs, especially 

for those without higher education are bad). 

The intersection of growing training and educational opportunities, increasing demand for 

rural health care workers at various levels, and changing rural demographics provides an 

interesting backdrop for this project. This study explores the following questions regarding the 

local opportunities for training and education in health care and the nature of the jobs which can 

subsequently be pursued after completion of local training or education: 

1.  How do individuals perceive local training and educational opportunities in health care? 

2.  How do individuals describe the characteristics of local jobs in rural health care? 



	
  

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The purpose of this study was to explore how local health care training, education, and 

labor shortages in rural communities are perceived by rural residents and how these perceptions 

fit in the larger social context. 

Methodology 

Study Site 

Names of places, people, and some occupations have been changed to protect the 

confidentiality of the participants and socio-economic information presented for this study site 

are based on the 2010 census which occurred just before the collection of this data (unless 

otherwise noted). Independence Creek, Washington is a small community located in the 

mountainous country of Eastern Washington, with a population of about 2,000 people, of which 

92% are white. According to the Washington Department of Health (2006), Independence Creek 

has a small town/isolated rural designation. Independence Creek’s population swelled during the 

early part of the 20th century, because of ample farming, logging, and mining opportunities. 

However, changing regulations and diminishing resources gradually led to a permanent decline 

in these industries over the past 40 years. In 1990, 37% of the jobs in Harrison County were in 

farming, natural resources, mining, construction, or manufacturing (Office of Financial 

Management, 2012). In 2010, these types of jobs made up just 25% of all employment. During 

this same period jobs in the service and health care sectors increased. The region took a huge 

economic hit in 2001 when a nearby mineral refinery plant closed, taking 300 of the last well-

paying jobs out of the community in a matter of three months. Although the health care sector 

only grew modestly while the community was losing the majority of its industrial jobs, care work 

became one of the primary pathways to stable, year-round employment. Thus, at the time of this 

study, the majority of good local jobs were concentrated in health care and education. Working 



	
  

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in these fields was also the primary way to gain access employee benefits. Harrison County also 

has a history of stubbornly high poverty, slightly elevated by the Great Recession. In 2010, 21% 

of all individuals living in this community and 24% of families with children under the age of 18 

lived in poverty (U.S. Census Bureau, 2010). After adjusting for inflation, annual wages in this 

county have remained stagnant since 1987, hovering around $30,000, well below the state 

average (Washington State Employment Security Department, 2010). Specific source tables for 

these figures are not identified to protect the identity of the county and community. Harrison 

County has also experienced a long history of higher-than-average unemployment. In 2010, 

Harrison County had a 12% unemployment rate, while an average of about 9% of those living in 

Washington experienced unemployment that year. Thirty-eight percent of men and 50% of 

women were not currently in the labor market in 2010 (Washington State Employment Security 

Department, 2010). This is compared to 28% men and 40% women at the state level. 

Local Health Care Training and Education 

In general, recruiting and retaining health care workers in rural areas has been a challenge. 

Health care administrators’ attempts to draw in and retain good nursing staff with incentives such 

as sign-on bonuses and extra vacation time have not been very effective (Lemay & Campbell, 

2010). One of the more successful strategies for recruiting and retaining rural health care 

providers is to recruit students from rural areas or who have rural connections (Molinari & 

Monserud, 2008). Physicians from rural areas are, on average, twice as likely to work in rural 

areas after graduation compared to their urban counterparts (Laven & Wilkinson, 2003).This is 

also seen as more ethical, as socialization and training for rural nursing is very different than the 

socialization process for urban nursing (The Frontier Education Center, 2004).  



	
  

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Independence Creek is about an hour from the nearest post-secondary two- and four-year 

educational institutions. While commuting is possible and definitely done by some, it can be time 

consuming and dangerous, especially in the winter. Some innovative programs have been 

developed by local health care and educational institutions in Independence Creek in an attempt 

to lessen the economic and social impacts of the labor shortages they experience in health care 

workers. The locally-delivered training and educational opportunities in health care in 

Independence Creek mirror many of the recommendations outlined by the Department of Labor 

in the Allied Health Access Guidebook (U.S. Department of Labor/Employment and Training 

Administration, 2010) which are designed to increase access and retention of high quality direct 

care workers. To follow is a brief discussion of each type of trainings available in or around 

Independence Creek. 

NAC/CNA certification programs. In Independence Creek, there is a well-established 

partnership between the local not-for-profit hospital and the high school. Nurse educators from 

the hospital have been providing an elective course titled “medical careers” for high school 

juniors and seniors for over 20 years in which the primary purpose is for students to complete all 

the requirements to become certified as a nursing assistant. Although this course is titled 

“medical careers”, the curriculum primarily focuses on nursing and direct care work, not careers 

in medicine. In addition to this opportunity in high school, the hospital also offers the traditional 

adult certification training three times a year. This is also a short course (ten weeks) for adults 

which focuses solely on completing the requirements for certification. This course and 

certification costs about $250. For high school students, the cost of the background check and 

testing fee are waived by the hospital and school. There are also scholarships and some 

government programs which occasionally help with the costs for both high school and adult 



	
  

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students. While the high school course is fairly unique, many rural communities have adult 

certification trainings. 

On-site Associates and Bachelors Nursing Degree programs. Independence Creek is one 

of the few isolated rural communities that have opportunities like their on-site associates degree 

in nursing (ADN) and distance degree bachelors of science in nursing (BSN). Employees at the 

Independence Creek Hospital have the opportunity to apply to the associates nursing program 

which is facilitated by a community college on the western side of Washington State. Employees 

may apply to the program after completing 12-15 prerequisite courses in science, math, and 

general education. Prerequisite courses typically take at least a year and are offered to 

Independence Creek residents in an online format, at a community college satellite campus about 

30 miles away, or at the main campus of the regional community college in Appleton (about an 

hour drive in good weather). Once accepted, students complete the rigorous two-year program 

which includes everything one could expect from a high-quality associates program delivered at 

a community or technical college. Because of the intense nature of this program and limited 

opportunity to interact with patients and other professionals in this remote rural community, only 

two students are selected each year. The total cost to the student is about $12,000 in tuition, 

books, and other additional costs. For nurses who already have associates degrees interested in 

administration, the hospital has partnered with the University of Great Falls to provide an online 

degree program for completing a bachelors. To date, only a few people have taken advantage of 

this program, but this collaboration reduces the total tuition costs for students from about 

$27,000 to about $7,000.  

 

 



	
  

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Research Design 

This study relies on data collected from November 2010 to November 2011, consisting of 

60 recorded, in-depth, semi-structured interviews with individuals with ties to health care 

training and institutions in Independence Creek and 40 hours of participant observation, 

primarily spent volunteering in health care settings. These methods allow for an in-depth 

understanding of how individuals perceive and experience the local health care educational and 

employment opportunities. The interviews covered a variety of topics related work and education 

experiences, migration, and perceptions of local employment and educational opportunities (see 

Table 1). Interviews lasted about an hour on average and ranged from 35 minutes to 2.5 hours.  

The bulk of the participant observation was conducted between June and October of 2011 

and took place mainly during volunteer shifts at the local long-term care facility. Volunteer 

activities included working with the activity aides to take residents via wheelchair to the local 

farmers’ market, the thrift store, and other community events, as well as playing cards and 

visiting with various residents. During these activities, I also interacted with staff and observed 

how they interacted with residents, patients, and each other. Most employees knew I was 

conducting a research study and were very friendly. Several were willing to take moments in 

their hectic work to explain the work they did and tell me a bit more about themselves, the 

residents, and patients. Because many of the questions asked respondents to talk generally about 

their experiences, individuals were free to talk about anything they felt was important.  

Interview Recruitment and Sampling 

The principal investigator originally made contact with and interviewed key informants in 

both education and health care. One of these key informants because instrumental in future 

recruitment of individuals who had participated in the local health care educational programs. 



	
  

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Thus, most of the respondents were initially recruited through the health care education 

coordinator at Independence Creek Hospital. Additional respondents were also recruited during 

participant observation. At the end of each interview, respondents were asked if they knew 

anyone else who would be interested in participating in this study and this resulted in 65% of the 

total sample being recruited through snowball methods. Purposeful recruitment was also utilized 

in an attempt to recruit types of individuals who were missing from the sample (such as men). As 

recommended in grounded theory (Wuest, 2012), as interviews revealed additional themes and 

questions, I specifically recruited individuals who could speak to those experiences or processes. 

Limitations of Methods and Recruitment Strategies 

While qualitative research provides a rich and in-depth examination of the social 

experience and environment, there are some limitations related to reliability and generalizability 

that should be noted.  First, the information collected here is assumed to reflect the actual 

experiences of those involved in the study. While trustworthiness can be an issue in qualitative 

research, this study focuses on the perceptions of those involved, regardless of their objectivity. 

When possible, I conducted interviews with multiple people involved in similar events or 

experiences. This made it easier to see commonalities and differences in their perceptions of the 

overall process. Next, recruitment of men was challenging. As in much of health care, men are 

very under-represented in health care in Independence Creek. Unemployed men and men in 

occupations outside of education and health care were difficult to reach and commit to 

interviews.  In a few instances, men canceled and rescheduled more than three times and never 

actually participated in a formal interview. Although gender comparisons are noted in this study, 

it seems the perspectives and experiences of the 21 men interviewed is more varied than those of 

the 39 women. 



	
  

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Table 1 

Brief Examples of Interview Questions 

 

Finally, and perhaps most importantly, the results of this are based on a non-random sample in 

one rural remote community and cannot be generalized to other communities.  It is hoped that 

the finding here regarding how the magnitude of health care as a primary industry and one 

community’s attempts at training, educating, and retaining health care workers is perceived and 

Questions 
Section 1: Introduction 

How long have you lived here? What brought you to Independence Creek? 
What do you like/dislike about living here? 
What types of jobs are available in Independence Creek? 

Section 2: Experience in Health Care, Education, and Work 
How did you become interested in health care work? 
What was your training like? 
Can you tell me about the people in your training/class? The people you work with? 
For people who did training, but didn’t pursue health care: 
What made you decide not to pursue health care?  

Section 3: Work 
What kinds of things have you done for work in the past? 
What did you like most/least? 
What do you do for work now?  
Probes: How long? How did you get this job? How do you like it?  
Are you looking for something else? Is it what you expected you would be doing? 
What type of work would you like to do in the future?  
Probes: What kinds of training/education/experience would that take?  
What kinds of opportunities do you have  for advancement?  
Would you consider pursuing these?  
Why or why not? 

Section 4: Family and Current Relationship Status 
What is your family/parents like? 
What did they do for work? 
Are you in a relationship? If yes, when/how did you meet? 
Do you have children? If yes, how old? What are they like? 
Can you tell me about a challenge you and your family have faced? 
Are you where you thought you would be at this point in your life? 

Section 5: Wrap Up 
Is there anything we haven’t talked about that you would like to share? 
Do you know anyone else who might be interested in talking with me? 



	
  

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experienced may provide insight for future research and other communities facing similar 

challenges. 

Data Analysis 

From the onset of this study, data collection and data analysis occurred concurrently 

(Glaser & Strauss, 1967; Wuest, 2012). Interviews and field notes were transcribed and coded 

for emerging and recurring themes using a grounded theory approach. The principal investigator 

wrote extensive memos and diagrammed relationships between emerging core concepts. Coding 

schemes were not pre-established and the very open and semi-structured nature of the interviews 

did not make it possible to specifically code answers to particular questions. Initially, open 

coding was used to review each interview transcript in HyperResearch Qualitative Data 

Management Software (2013). As coding progressed and new codes emerged, earlier transcripts 

were back-coded. In total, 35 content-specific initial codes emerged. The codes represented in 

this paper are specific to the research questions outlined previously (which emerged as the study 

evolved), including participant reflections on the positive and negative characteristics of 

education and work in local health care, especially those related to availability, upward mobility, 

pay, stability, workplace qualities, and residential migration. After the initial coding, reoccurring 

groups of codes were further investigated and theorized as themes regarding perceptions of 

opportunities, job characteristics, and beliefs about residential migration. This data was entered 

into excel and then transferred to Stata, a quantitative software package (StataCorp, 2013), to 

calculate cross-tabs regarding the occurrences of codes and themes by respondent characteristics 

(such as gender, education level, and job status) for descriptive purposes. When appropriate, 

differences in perspectives and responses across categories are also noted. 

 



	
  

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Findings 

Respondent Characteristics  

This project first received exempt status from Washington State University’s Institutional 

Review Board (IRB # 11637) in November of 2010 and an approved status (IRB Number 

#12016) in June of 2011 when more extensive participatory observation was added to the study. 

Ninety percent of the respondents were white (reflecting the racial make-up of the county) and 

they ranged in age between 17 and 70. Sixty-five percent of those interviewed for this study were 

women and 55% were either married or cohabitating. Sixty-three percent were parents with 

children ranging in age from birth to 45, and 42% of the parents were either single at the time of 

the study or had experienced significant periods of single parenthood in the past. Aside from the 

five participants who were still in high school, all respondents had at least completed high 

school. Forty-seven percent had either high school diplomas, GEDs, or some college. Only six 

respondents had two-year associate degrees, while the remaining 21 (35%) had a four-year 

degree or higher. This is atypical of the general population in Harrison County and reflects the 

fact that most of the people interviewed were working in a field that usually requires college 

degrees for any type of upward mobility or status. Eighty-two percent of the respondents were 

employed at least part-time. Seventy-six percent of employed respondents worked in health care. 

Eleven respondents (18%) were either full-time students, stay-at-home parents, or retired, thus 

out of the labor market.  

Opportunities in Health Care 

To address the first research questions regarding individuals’ perceptions of the local 

training and educational opportunities in health care, it is clear that some respondents found the 

local opportunities in health care training and post-secondary education to be insufficient, while 



	
  

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others felt they were very advantageous (see Table 2). Of the 21 respondents working as CNAs, 

81% (n=17) expressed a desire to gain training and education that would allow for upward 

mobility in the health care field. Forty percent of the respondents (n=24) mentioned the local 

opportunities were not really effective or ideal, while 55% discussed why they were helpful and 

important in their community. The unique characteristics of these coding clusters are further 

detailed below. 

Table 2 

Count of Cases Describing Themes related to Local Educational Opportunities 

 

Of the individuals who suggested that they felt the locally-available educationally 

opportunities were not effective, three related, but distinct themes emerged. First, 54% (13 of 24) 

discussed the local options being too expensive, time-consuming, and often required burdensome 

commuting. Scott, a 43-year old nurse with a two-year nursing degree who aspires to become a 

physical therapist, discussed the difficulties he faces in deciding how to complete his 

prerequisites while living in Independence Creek.  

You are currently finishing up your prerequisites - how are you doing that?  

“Online. I have weeded out as much as I can do online and then have to go back for 

Anatomy and Physiology and one more physics class”. 

Theme Case count* 
Local educational opportunities as insufficient because… 24 

they are expensive, time-consuming, and require commuting. 13 
they do not exist, are extremely limited, and require out-migration. 9 
there are too few slots and they are too selective. 8 

Local educational and employment opportunities in health care are helpful because… 33 
they are a stepping stone for those interested in health care.  23 
they give place-bound and high school educated people access to training. 24 

*Some cases mention more than one of the themes presented here.  



	
  

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Where do you think you will do those? 

I am looking to take a little bit of time off and probably finish them up next spring and 

summer quarter, if they are offered then. Probably through [Appleton Community College] 

or one of the schools down the way…Whichever one is cheaper. 

In reality, Scott’s goals of completing physical therapy school will eventually mean 

moving, at least for a few years, as the closest school with a program is four hours away, but for 

now, Scott is at least making plans and taking the immediate steps towards his goal. When 

considering the on-site nursing program, others expressed concern about going into debt to pay 

for the $12,000 in tuition, fees, books, and supplies. Others simply struggled to think about how 

to finish the prerequisites. For instance, Monica, a 27-year old single mother of three had this to 

say about her hopes of pursuing a nursing degree: 

I have to do a ton of prerequisites, because I’ve never done any kind of college. I have my 

GED, that’s it…I think I have two and a half years of prereqs…I don’t know what all kind 

of classes…There’s [Wrightburg] campus and then a couple different colleges in 

[Appleton]…Some of it— I would try to purchase a computer first and do on-line, because 

a lot of the prereqs you can do on-line, ‘cause I don’t want to go to school every day. I 

mean, if I can do it at home on a computer, then I would rather do that.  

Although the small satellite campus in Wrightburg is only about 35 minutes away and 

offers a limited number of courses for local students, it is still a large commitment for a single 

mother like Monica. Also included in this group of individuals who were disappointed with the 

locally-available education were some who had obtained a degree while commuting to Appleton 

up to seven days a week for several years. While some found commuting an acceptable cost for 

furthering their education, others felt the price was too high. Holly, a 24-year old married mother 



	
  

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of an infant and part-time NAC at the hospital shared this about her experiences with commuting 

to Appleton in an attempt to complete her prerequisites for nursing school: 

I would commute and it got as bad— ‘cause I tried to take as many classes in [Wrightburg] 

as I could and then about my last year of my prereqs I had to do all of my classes in 

[Appleton] and they would be as bad as five days a week, and then you’d turn around and 

be like, that’s 10 hours a week just on commuting. 

In addition to concerns about expenses, time, and travel, nine of the 24 in this coding 

cluster rejected the feasibility of commuting and argued that local educational opportunities did 

not really exist or were extremely limited, and therefore, the pursuit of training or education 

required moving out of town. Constance, a 24-year old single woman who moved 65 miles away 

from her hometown to pursue her dental hygienist certification in Appleton had this to say about 

her experience with nursing assistant work, education, and migration:  

My last year working there I started school in [Wrightburg]…I took as many of the 

prerequisites as I could, but eventually I ran out—I had to head to [Appleton]. So that’s 

why I ended up putting in my notice so I could just focus completely on school and get 

into the program…I have moved a few times, but just stayed in [Appleton], just getting 

closer and closer to school. 

Eight of those who felt the local training and educational programs in health care were not 

useful, argued this was primarily because there were too few slots for students and that the 

existing programs were too selective. This was especially true about the high school medical 

careers class and the on-site nursing degree program. While singing praises for the success of the 

medical careers class, Bill, a 52-year old married high school history teacher had this to say: 

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opportunities…but she only accepts eight kids and so there’s a limit to the amount of 

opportunity.”  Martina, a 20-year old single woman who has worked as a full-time nursing 

assistant in acute care for two years had this to say about her chances of getting into the on-site 

nursing program: “The people who typically get it first are the ones who have worked here…and 

it’s basically first come, first serve.”  

Finally, although there was rarely more demand for the Adult NAC course than could be 

offered, when asked if the program was capped, Meg, the Director of Education for 

Independence Creek Hospital had this to say: “I do try to cap that one at eight…because, they’re 

coming in and they were loggers, you know? Are you ready for peri-care?” Quality of training is 

important to Meg and she feels this can be partially addressed through small class sizes. She also 

went on to talk about the increasing demand for the on-site nursing program: 

We have phone calls about it every week now. [The on-site nursing program] is getting 

out…In fact, I’m starting a new adult NAC class…and probably taking 8 students again, 

and at least 3 of them are [on-site nursing program] seeking students. I mean, they are 

right up front with me.  

While the on-site program is still new, community members are becoming more aware of 

and interested in pursuing the opportunity. As Meg points out, 38% of her incoming adult 

nursing assistant class are taking the class because they know it is the first step to entering the 

on-site nursing program. Despite some negative comments on the locally-available training and 

educational opportunities, most of the negative feedback was related to a perceived lack of 

opportunities, not necessarily that the opportunities are of poor quality or unappealing. In fact, 

many more individuals felt the training and education in Independence Creek was very useful for 

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Fifty-five percent (33 of 60) of the respondents reported that they felt the high school 

medical careers class, adult NAC course, and on-site nursing degree programs are positive assets 

for individuals and the community. These responses can be categorized into two main themes. 

Some described how individuals who were college-bound used the NAC trainings as a way to 

get medical experience on their way to college. Others focused on providing opportunities for 

place-bound and high school educated people who were not planning on leaving Independence 

Creek. 

A total of 23 people (38% of the respondents) described becoming certified as a nursing 

assistant as a “stepping stone” or a way to get into the medical or nursing field. While 15 of the 

23 currently worked in health care, the remaining supporters did not. This perspective was shared 

by younger and older respondents, although most respondents in this category discussed these as 

opportunities for younger adults. Leslie, a 17-year old junior at Independence Creek High School 

interested in becoming a nurse felt the class was “a way to get your foot in the door…to get 

exposure in the medical field.”  Two college-bound young men who became certified within the 

last two years felt strongly that the class was a very good place to start in their pursuit of higher 

education in medicine. Brent, a 17-year old high school junior noted,  

In talking to people that are in the medical field, it seems like people are a lot more 

respected when they’ve worked as a CNA. They’ve worked as a nurse. They’ve worked 

those lower, mid-level jobs in medical before— instead of just going straight and being a 

doctor and being a doctor who has no point of reference and in their eyes maybe less 

respect for the jobs that they do just because they didn’t spend an extra four years in 

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Although these individuals sometimes also expressed distaste for the type of work that was 

required of NACs (especially in long-term care), they still expressed positive views for the class 

and work in general. Nicole, Brent’s 20-year old cousin who works in fast food while being a 

part-time community college student and who also took the high school class share that while her 

younger cousin “doesn't necessarily like the CNA work, it’s a stepping stone to get to where he 

wants to be.”  While these three respondents were fairly young, this perspective was shared by 

their old counterparts from the adult NAC course. Pamela, a 40-year old divorced woman 

making a career shift out of warehouse work described her enrollment in the class as “a good 

step” and one that would “open the door” to other opportunities. Nurses and administration also 

described the class as a good place to start for people interested in a career in health care, even 

though they did not take that route themselves. Robin, a 35-year old nurse manager at a local 

long-term care facility said that although she did not take the class herself, she really felt the 

individuals who did were “already a step ahead in the nursing field.”  Four mentioned this work 

as a good “college” job. Meg, the Director of Education at the hospital nearing retirement told 

me, “You know, even these kids that are gonna go to four-year school schools, most of them 

need to have a job, so what’s wrong with being a CNA?”  Finally, an additional ten people in this 

category expressed interest in the on-site nursing program and identified NAC certification as the 

first step to being accepted. Clearly, interest in and awareness of this program is high, especially 

among lower-status health care workers. 

Although related to the idea of the class being a stepping stone, a second group of coding 

clusters emerged around the idea that the local trainings were very positive for the community 

because they give place-bound individuals and those with only high school diplomas the 

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these individuals might be qualified for. A total of 24 individuals either conceptually argued that 

the training and education were good for other people, or expressed that they themselves had 

benefited from having these opportunities. The five respondents who discussed how the 

opportunities are good for others in the community, primarily focused on these jobs as those 

well-suited for young women, especially those with children. Valerie, a 35-year old remarried 

mother of four teenage children who took the class herself in high school before becoming a 

dental assistant summed up the sentiments of several respondents regarding the role of these 

trainings in Independence Creek: 

It give a lot of these kids, like there was a pregnant teenage girl, who had a baby and I 

don’t know if she’s even stayed in or if she’s gone to college or what she’s doing, but it 

gave her a little bit of hope. I wish they would open more [slots], even just [for] girls who 

don’t think they’re gonna go anywhere in their lives…it gives these girls something. A job, 

some training – they’re not gonna go to college. They’re not gonna get out of this town, but 

at least let’s help them not be on welfare. Let’s get them a training before they get too far, 

where all their doing is living off the system. 

For women who were not college bound or likely to out-migrate, becoming a direct care 

worker could provide them with fairly stable employment in an area important to the community. 

Six of the women in the study discussed how the training and subsequent employment helped 

them get on their feet and establish themselves in the community.  

These trainings can also be important for those who never want to leave Independence 

Creek or find themselves either returning or in-migrating for various reasons. Fifty-eight percent 

(14 of 24) discussed family ties and support as the reason for being place-bound in Independence 



	
  

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Creek and all of them were women. Dawn, a 25-year old single mother of one moved back to her 

home town after her father was in a car accident and required extensive rehabilitation.  

I ended up leaving to come back here after just a couple months because of [my dad’s 

accident]. So I ended up moving back here because I can’t afford— my mom watched 

[Lenny] for me for free and I can’t afford childcare, so, I just wounded up moving back 

because mom was here with [my dad].  

Becoming a CNA enabled Dawn to both care for her father and support her son, but she 

could not afford to work if her mother was not providing child care for her while she worked the 

evening and night shifts. Her story was quite similar to three other single mothers in this study.  

In sum, more individuals saw the local training and educational opportunities in health care 

in Independence Creek as more positive than negative. Indeed, most of the complaints regarding 

the local opportunities regarded a need for more slots and variety. Those who felt positively 

about the trainings and education tended to see these as a stepping stone, especially for those 

who are college bound. On the other hand, several individuals felt the trainings and potential 

employment provided viable alternatives for individuals, especially young women, who might 

not otherwise be able to acquire stable employment because of their desire to stay in 

Independence Creek, family obligations, or their lack of education. Valerie, the 35-year old 

mother of four summed up what many had to say about the positive impacts of having this type 

of course in the community by sharing about her own experiences with the high school medical 

careers class 17 years earlier: “It gave me such a head start, even for my dental assistant class, it 

gives you such a head start with everything and I think this medical careers class is just the best 

class to have in this community.” 

 



	
  

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Perceptions of Job Characteristics 

The second research question explores how respondents felt about the available jobs or 

occupations in local health care. Regardless of whether or not the training and education 

opportunities were seen as negative or positive for the community, many people in this study had 

something to say about the characteristics of the jobs which local individuals were being trained 

for (see Table 3). When respondents discussed work in health care, pay, security, and stability 

were topics that came up often, with 67% of respondents (40 of 60) mentioning at least one of 

these themes.  

Pay as an important consideration. Among the 23 respondents who discussed pay for 

CNAs and other DCWs, 70% (n=16) felt the pay was not good. Four people specifically 

mentioned that DCWs were “overworked and underpaid.”  Constance, the young woman living 

in Appleton and finishing her dental hygienist certification shared: “The NAC work was great 

but, you know, you max out at $15, anymore. That’s not enough to support yourself.”  Emily, the 

mother of three young children and full-time unit clerk expressed her frustration with the 

differences in pay among low-level positions in the hospital and long-term care facility. “[Long-

term care] was hard, physical work and you get paid less doing that than just paper work.”  

Rebecca, the married young mother of four girls explained why she is not currently using her 

certification:  

It’s important, like I said, for me to stay home with my kids. Especially— I mean, I love 

being a CNA, but you don’t make real good money. So, I would be working just to pay for 

daycare and what’s the point? I would much rather be with them. 

 

 



	
  

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Table 3 

Count of Cases Mentioning Themes related to Job Characteristics 

Theme Case Count 
Pay 29 

For CNAs and other DCWs 23 
For nurses 10 
For rural health care, in general 11 

Job security 21 
For CNAs and other DCWs 7 
For nurses 8 
For rural health care, in general 6 

Job stability 19 
Disliked unpredictability 15 
Valued flexibility 4 

Workplace stability 24 
Unstable funding 6 
Organizational changes 6 
Fears of closures, layoffs, and understaffing 4 
Felt workplace was stable 3 

 

Despite what some perceived as very low pay for very difficult work, seven respondents 

(five of whom were under the age of 25) felt the pay was good, especially compared to other 

entry-level service jobs. Wendy, an 18-year old who landed a home health aide position after 

taking the medical careers class and who hoped to become a pediatrician someday, had this to 

say:  

You actually go into their home and help them. It’s really cool. [My aunt] was really 

excited when I told her I took this class…‘cause I work at [Burger King] and they get 

significantly a lot better [pay] than you do at fast food— I just like the idea of helping 

people. That’s always been my kind of thing. 

Three of the seven noted the slightly higher than minimum wage starting pay as a real 

incentive for entering direct care work, even if the work was not ideal. Leslie, the 17-year old 

high school senior who is interested in dermatology explained how she knows people who were 



	
  

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making $10 an hour doing this work and how “awesome” that would be. She shares, “You know, 

you wouldn’t think $2 [an hour] would help that much, but it makes the biggest difference.”  

Hospital and school administration also pointed to the slightly higher than minimum wage pay as 

a significant incentive for young people to become certified as nursing assistants. Compared to 

the mixed feeling about pay for CNAs and other DCWs, the ten respondents discussing pay for 

nurses almost universally agreed the pay was good. The one exception was a well-established 

nurse who argued that despite the good pay, single mothers who worked as nurses were not able 

to afford the health insurance premiums to cover their children. Finally, among the 11 who 

discussed pay in rural health care, 73% argued the pay was poor compared to urban health care 

settings while the other three suggested that the pay was adequate, especially if you considered 

the cost of commuting to urban places. For these respondents, moving for better employment or 

pay was generally not something they would even consider. 

Job security as a strength. Respondents’ feelings about the ease of locating, securing, and 

maintaining employment in their field or having a sense of job security, was also important in 

this study. Thirty-five percent of respondents discussed how having skills and training in health 

care and more specifically, nursing and direct care work, gave either themselves or others in their 

community security in the local labor market. While six respondents generally considered health 

care as secure, an additional 13 talked specifically about nurses and CNAs (seven and six, 

respectively). As Tina, a 36-year old married mother of two who returned to Independence Creek 

after completing her bachelor’s in nursing notes, “Not many people can find jobs…unless you 

have a degree in some education or nursing field or, medical field.”  When Phillip, the 55-year 

old logger-turned-nurse, was asked why he decided to go into nursing, he also noted changing 

demographics. “I think the biggest thing was I knew it was a steady job because baby boomers, 



	
  

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we’re just getting older— I’m a baby boomer. They need care. You don’t get too many layoffs. 

And you can find a job.”  Sherry, a 33-year old married mother of four boys who works nights as 

a CNA in long-term care was well aware of the changing demographics of the nursing 

population and shared her own experiences with who she saw in classes at the Wrightburg 

satellite campus when she was completing her prerequisites to apply for the on-site nursing 

program: “It is a good field for younger people to get into because there should be openings in 

the future as most of the work force is looking to cut back or retire. So a lot of people there were 

trying to get into nursing programs.”  Seventy-five percent of those who discussed job security 

for nurses felt it was very good.  

Opinions regarding job security for CNAs and other DCWs were similarly positive. All the 

respondents who discussed job security for CNAs and other DCWs felt that these occupational 

lines in health care provided a lot of security. Stephanie, an 18-year old CNA at a local long-term 

care facility reported that she regularly encourages her friends to take the NAC training because 

“You always have a job somewhere, because somebody is always gonna get sick.”  Martina, the 

young NAC in acute care who aspires to become an ultrasound technician, shared a similar 

perspective, although she was not as enthusiastic as Stephanie about her decision to become an 

NAC. “NACs are kind of – I wouldn’t say that they’re in high demand, because for a penny, you 

can have ten aides, but typically, you can find a job almost anywhere…It was an okay choice.”  

Finally, 100% of the respondents who generally discussed job security in rural health care felt it 

was strong. With the exception of the two respondents worried about too many nurses entering 

the current labor market, 90% (17 of 19) of individuals who discussed job security in health care 

felt it was a reliable field to enter. 



	
  

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Job stability as a challenge. The topic of job stability (i.e., consistent hours and schedules) 

was also a topic that emerged as important to about a third of the respondents. All 19 of those 

who discussed job security also worked in health care, meaning it was a salient issue for about 

one in every two health care workers. Problems with shift work, being supplemental, on-call, and 

sent home because of low census were all mentioned. Tina, a 36-year old nurse administrator had 

this to say about her early career in nursing:  

At that point in my life I…had a small child…And I was going through a divorce and I have 

a lot of family here and they are a huge support for me, but working evenings, or working 

nights, it was too hard to leave her at a stranger’s house or find a babysitter for those 

hours.  

Being supplemental meant holding a position in which workers sign up for as many open 

shifts as they like at the beginning of the month, as long as they do not exceed full-time or 40 

hours a week. These are used primarily for DCW and RN floor positions. While flexible, the 

drawback of these positions is that sometimes full-time work cannot be obtained, and even when 

workers sign up for full-time work, supplemental workers are the first ones to go home if there 

are not enough patients to care for. In general, census remains stable in long-term care, but 

workers are often called off or sent home early on the hospital’s acute care floor. Even for nurses 

who earn a better wage, this can be problematic. For instance, Joe, a 45-year old married nurse 

supervisor and former Marine highlighted the instability of patient census in rural hospitals: 

You’re already at one or two or three nurses, so if you lose those patients…every other 

person, you’re going home. Verses a large hospital, you might have six or seven nurses per 

shift, so now you’re one in six to get it…So you may be sent home, and being sent home 



	
  

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every other day during your cycle of shifts, because they don’t have the patients – who can 

afford to lose 50% of their pay checks?  

Typically, new CNAs start at the hospital or in long-term care as supplemental. While 

individuals in these positions accrue sick and vacation time, they generally do not have the 

option of health insurance benefits. Seventy-nine percent (15 of the 19) of respondents talking 

about job stability reported they disliked the unpredictability in their hours, schedules, and 

subsequent pay. Despite being described by others as one of the long-term care facility’s best 

employees, Stephanie, the 18-year old nursing assistant expressed frustration about the stability 

of her hours:  

I first started working as supplemental and going to school, and once I got out of doing 

supplemental I had a lot of hours and then, out of nowhere, they just totally dropped to 

where I was only getting maybe $300 on a paycheck— that was it. Driving back and forth 

from school from where I was living, that just wasn’t cutting it. 

Still, four individuals did report that they valued the flexibility that came with working 

supplemental because it was easier to work around a second job, family obligations, and school. 

Debbie, a 30-year old single mother who works supplemental as a nursing assistant while she is 

completing her prerequisites for the associates degree program in nursing explained that “[They] 

are really, really willing to work with you. I never know what my schedule is going to be from 

quarter to quarter, so this helps. I like to keep busy, but I like the flexibility.”  Those working in 

acute and ER are more susceptible to being sent home because of low patient census or a lack of 

need. Some found that being an RN helped protect against some of the negative aspects related 

to job stability. For instance, Tina, a 36-year old nurse administrator and single mother of two 

who complained about the unstable schedule eventually pursued her BSN that would allow her to 



	
  

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demand a more regular schedule. While working in health care was perceived as providing good 

job security, many respondents found the low pay and job instability frustrating. Obtaining 

bachelor’s degrees allowed some to avoid these negative aspects.  

Work place stability sometimes concerning. Finally, although related to pay, security, 

and job stability, work place stability (i.e., little fear of layoffs, closures, or downsizing) was also 

a separate topic that emerged in this study. During the time this study took place state support for 

rural health care facilities, especially those in “critical access areas,” was being considered for 

reduction because of the massive cuts the Washington State legislature needed to make to the 

annual budget. Washington State laws require that the budget be balanced every year, which in 

lean times puts a lot of pressure on education, health care, and other social services heavily 

funded by state dollars. Jackie, a 37-year old shower aide in long-term care and divorced mother 

of six expressed her concern about the stability of rural health care and an upcoming vote on 

budget legislation: “You hear about our financial difficulties and how if this thing passes on the 

28th, a lot of rural hospitals will be closing down and it’s scary.”  Furthermore, the nature of the 

rural population (older and poorer) means rural hospital and health care systems rely heavily 

upon government reimbursement for care through programs like Medicaid and Medicare. 

Independence Creek is no exception, with 85% of long-term care residents on state-sponsored 

health insurance and 60-70% of emergency room, in-hospital and out-of-hospital patients either 

on state-sponsored health insurance or uninsured all together.  

During this study, several employee forums were held by hospital administration to discuss 

the impending budget crunches, shortfalls, and potential cuts. These forums were attended by 

employees at various levels of service, although those outside of the direct care work delivered in 

acute and long-term care had more flexibility to leave their offices and current tasks to join the 



	
  

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discussion. Despite the hospital’s attempts to calm employee concerns about potential closures or 

changes in services and benefits, the threat to rural health care was mentioned by 27% of the 

respondents (16 of 60) and all but one of these respondents worked in rural health care. Debra, a 

45-year old married mother of two grown children who works as a paraprofessional at the middle 

school had this to say about her own concerns: “I’m thankful that we still have a hospital here, 

[Green Meadows] closed theirs. They just have an urgent care and so, we’re lucky. I’m hoping 

that we keep it.”  Ten of the 19 who mentioned workplace stability issues were primarily 

concerned about unstable funding, potential closure, layoffs, and understaffing. Another six 

discussed some of the recent organizational restructuring that was occurring to streamline 

positions and eliminate waste in the labor force. Valerie, the 35-year old dental assistant who 

formerly worked in long-term care as a nursing assistant and has family that works at the hospital 

explained her perceptions of a growing workload:  

They don’t want to hear that you don’t have time. You add more, but your room isn’t 

getting cleaned or your patient was mad, you know…that could just be the economic times, 

but I feel like it’s just over the past I don’t know how many years, it’s just gotten worse and 

worse. Even before the recession. It’s always been, “Do more with less.”  

Not everyone felt rural health care was unstable or that the community was in jeopardy of 

losing its hospital or the local jobs in rural health care. Carolyn, a 53-year old hospital 

administrator who has worked for Independence Creek Hospital for more than two decades had 

this to say: “We’ve gone through some changes and had some growing pains, but things seem to 

be going well.” Janis, a 52-year old board member of a local agency which addresses the needs 

of the elderly within the community discussed the stability of home health care and services:  



	
  

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I think it will have to become more important. I think with the Medicaid cuts and the 

Medicare cuts that are looming and the ones that already happened, homecare is the least 

expensive alternative if the person is able to be at home without skilled nursing. Then any 

home care agency is able to fill that gap at the least cost. 

Janis is well aware of the budget crunches local health care faces, but feels strongly that the 

need for care, especially home care will persist and continue to require a local labor force. In the 

end, community members and those working directly in health care expressed awareness of 

potential instability in rural health care funding and employment, but health care was still seen as 

a stable occupational choice by more than a third of the respondents, even if the organizational 

structure of care delivery changed. 

Discussion 

This project explored individual perceptions and beliefs about local training, educational, 

and employment opportunities in health care. More specifically, this study revealed important 

information about perceptions of opportunity and work characteristics among rural residents in 

one isolated community where health care is one of the main avenues to local employment. 

These beliefs and perceptions about education and employment are embedded in larger systems 

and locally-constructed social hierarchies in Independence Creek that often support patterns of 

behaviors that create opportunities for some while limiting opportunities for others (Sherman & 

Sage, 2011). In rural communities like Independence Creek, beliefs about independence and hard 

work are often incorporated into how individuals are judged by those around them (Sherman, 

2009). This study illuminates how jobs in health care might provide avenues for some to show 

their ability to work hard and be independent, depending first on how these opportunities are 

perceived. 



	
  

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Serving Dual Purposes: Local opportunities in health care 

Most people in this study perceived the local training and educational opportunities 

favorably. In fact, more than half said they were valued and desired to have them in their 

community. Even the respondents who shared negative comments regarding the opportunities 

felt this way mostly because of the limited nature of what was currently available locally. Beliefs 

about who was best suited for the local trainings fell into two general categories. For 38% of the 

individuals, local training and educational opportunities in health care provided a jumping off 

place. Most individuals who saw the medical careers class or the adult NAC course as a 

“stepping stone” also performed well in high school and others in the study perceived them as 

college bound. In general, respondents believed post-secondary education could only be pursued 

outside of Independence Creek and therefore, they tended to feel that while the entry level 

classes were useful in getting exposure to the medical field, the local training and educational 

opportunities, in general, were insufficient. Additionally, family background and social status 

contributes to the likelihood of college attendance of rural youth (McGrath, Swisher, Elder, & 

Conger, 2001; Provasnik et al., 2007; Sherman & Sage, 2011; Wilson, Peterson, & Wilson, 

1993) and therefore, this could mean that inequality is being reproduced, at least among the more 

privileged families in Independence Creek. Alternatively, 40% felt the local training, 

educational, and employment opportunities in health care provided a suitable alternate route to 

stable employment either with or without the pursuit of post-secondary education. This is 

important when considering how non-college educated individuals earn status or respect in the 

community where most of the good jobs of the past are gone. While some individuals in this 

group tended to believe the local training and educational opportunities were not sufficient, the 

majority saw these as good for place-bound individuals who either could not or did not want to 



	
  

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leave Independence Creek. They appreciated the local opportunities and a few complained there 

were too few slots in the on-site nursing program, which they saw as very valuable.  

The respondents describe the pay for CNAs and other DCWs as good, or at least better, 

than other entry-level service jobs. Some, like 17-year old Leslie, were enthusiastic about the 

pay, while other like Martina, described their decision to go into direct care work as “an okay 

choice.” These individuals also worried about job and workplace stability, but generally felt they 

could always find work with their certification. The majority of individuals in this group either 

forewent college all together in favor of staying in their rural community or managed the 

difficulties of pursuing post-secondary education without ever leaving. While low pay and a lack 

of stability make most of the opportunities in rural health care in Independence Creek bad jobs, 

participants expressed discourses to justify or explain persistence in these positions. Parenthood 

and other family obligations made staying in Independence Creek important to these individuals. 

The slightly higher than minimum wage pay places these positions above other service sector 

opportunities in the hierarchy of employment in Independence Creek. Others argued that the 

flexibility of working in supplemental or on-call positions was something that worked well with 

the other demands in their lives. Nevertheless, the majority of respondents who discussed pay for 

direct care workers agreed that the pay was too low for the level of physical and emotional 

demands.  

Regardless, for individuals who could not or did not want to leave Independence Creek, 

local training, education, and employment provided a much needed opportunity. This was 

especially important for young women with children. For those who were staying in 

Independence Creek, the local pursuit of post-secondary degrees still primarily meant 

commuting to Wrightburg and Appleton. It seems that this reality may continue, despite the 



	
  

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introduction of the on-site nursing program. Ten individuals currently working at Independence 

Creek Hospital and their long-term care facility as NACs expressed interest in the program 

which can only take two new students per year. While it does not appear that upward mobility is 

going to be readily available to everyone who enters low-status health care work, for some 

simply entering this type of work gives them a sense of elevated status. Moving beyond this 

small increase in upward mobility may be difficult. 

Overall, the locally-available trainings and education in health care are desired and valued. 

Although most felt that pay and stability in health care was not very good, it appears that job 

security tended to out-weight the negative feature of this type of employment. This study builds 

on what Probst, Baek, and Laditka (2009) found when comparing rural and non-rural 

respondents in the National Nursing Assistant Study (NNSA) of 2004. These researchers found 

that while nearly all CNAs, on average, noted that they became CNAs because they liked taking 

care of people, when asked to rank their reasons, rural CNAs ranked job security or a job close to 

home as most important, while urban care workers ranked caring for people as most important. 

Having options for staying, even if they are not ideal, appears to also be important for those 

wishing to remain in Independence Creek. 

If Washington State wishes to meet the project demands for nurses and other care workers 

in the future, nursing education will need to be expanded. There are simply too few slots in both 

campus and off-campus programs to graduate enough nurses to fill the projected needs. This 

factor is something that state officials and health care administrators have been aware of for 

some time (Skillman et al., 2007), but this study uncovers how potential students view the 

problem of too few slots and limited access. Although this study focuses on how locally-

available training and education was perceived, 42% also discussed wait lists for ADN programs 



	
  

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in Appleton and problems with these programs maintaining their ability to license students. 

Therefore, even those rural residents who are willing to commute or move in order to pursue 

nursing degrees often run into problems with enrollment. Whether it is through on-site rural 

nursing programs or through expanding traditional campus programs, Washington State should 

set its sights on expanding nursing education. If policy makers are specifically interested in 

recruiting and retaining quality nurses for rural areas, it seems that recruiting directly from the 

local community have shown the greatest potential with physicians (Laven & Wilkinson, 2003), 

and may be the best option for although much more research is still needed on this subject in 

relation to on-site programming and nursing. 

 

Supporting Agency 

Department of Labor: Education and Training Administration 

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