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At the ɫ��ֱ�� First Annual Rural Health Symposium, the audience emphasized key common terms in crowd-sourced word cloud activities: innovation, collaboration, and community.

“It was gratifying to see the group coalesce around these themes, since a key driver of this event has been the idea that innovation comes from collaboration,” said Dr. Devon Noonan, Associate Dean for Community Engaged Science and Director of Rural Health Equity.

The symposium brought together healthcare professionals, educators, researchers, community leaders, and policymakers for a one-day symposium dedicated to reducing rural health disparities across North Carolina.

In his welcome remarks, School of Nursing Dean Michael Relf acknowledged some of the challenges related to rural health, including that in 2028, rural shortages of registered nurses (RNs) are projected to reach 24%, versus 5% in urban areas; that rural Americans have higher rates of hypertension, obesity, COPD, and multiple chronic conditions and experience 40% higher preventable hospitalization rates; and that they are more likely than urban residents to die prematurely from heart disease, cancer, stroke, and chronic lower respiratory disease.

“While the challenges we’re facing are significant, we know that real progress is possible when we work together to address these interconnected issues in ways that center and honor local strengths,” Dr. Noonan said.

Assessing Opportunities for Growth & Change

In the symposium’s opening keynote, “Designing the Future of Nursing for Every Zip Code,” Erica DeBoer, Chief Nursing Officer at Sanford Health, surveyed the current nursing landscape and outlined opportunities for growth—particularly in rural settings.

Drawing on her experience living in Lennox, South Dakota (population 2,600), DeBoer emphasized that rural healthcare resists one-size-fits-all solutions. “You don’t really understand it unless you work there,” she said. Many nursing guidelines, she noted, assume access to resources or staffing levels that rural facilities simply don’t have. Effective guidance for rural practice must explicitly address low-resource, low-volume environments and be paired with continuing education grounded in real-world constraints.

DeBoer underscored that while nurses are well positioned to address social determinants of health across care settings, rural nursing models are often fragile. Limited staffing, fewer opportunities for leadership knowledge transfer, caregiving responsibilities outside of work, and the need to generalize rather than specialize all add strain. She pointed to solutions such as intentional recruitment and retention strategies, childcare supports, licensure and reimbursement flexibility, mental health resources, and deliberate transition planning to strengthen rural nursing teams.

Virtual care, DeBoer said, holds promise for expanding access but should not be framed as a substitute for in-person care. Language barriers, disability, cultural differences, and digital literacy gaps can limit its effectiveness if virtual care is treated as a cure-all.

She also addressed nursing shortages, which are often more acute in rural areas, and the downstream effects of limited clinical placements on rural nursing programs. Investing in rural-based education and faculty development, she argued, is critical. “If we can get them to do clinicals and work in rural settings, then they want to stay,” she said.

DeBoer stressed the importance of nurses practicing to the full scope of their licensure. “We’re adaptable, we’re flexible,” she said, “and we have the opportunity to continue to show and care in different ways if we’re allowed to practice to the full scope of our license.”

In closing, DeBoer called for immediate action: strengthening rural health content in nursing curricula, expanding continuing education aligned with evolving rural needs, aligning loan repayment and scholarship programs with rural service commitments, funding rural training tracks and preceptors, supporting interprofessional rural teams through policy, and ensuring rural nurses are represented in planning, governance, and decision-making.

“True health equity, resilience in difficult times, and value-based care implementation require fully enabled nursing leadership across system strategy and governance,” DeBoer said. “Are we at the right tables as nurses, and are we asking the right questions?”

Insights into the Future of Nursing

A panel of experts moderated by Professor Rosa Gonzalez-Guarda discussed various aspects of report. Below are some insights from Erica DeBoer; Dr. Trish Baise, Chief Nursing Executive of ECU Health; and Dr. Beth Merwin, Professor at UT-Arlington.

Beth Merwin: “We've got lots of people who want to be nurses. What we need help in is opening the doors so that those who want to be prepared are fully prepared and can gain entry in an expedient way to the programs they need.”

Erica DeBoer: “When you think about innovation and transformation, it's incredibly important to find industry partners. […] We're helping our frontline providers become inventors.”

Trish Baise: “Sometimes we're being invited in when they're clearing the dang dishes. We need to be invited in as policies are being shaped. Of 15,000 team members, 5,000 are nurses. If we're all speaking together, that voice becomes very strong.”

Serving Rural North Carolinians

In the symposium’s second keynote, Maggie Sauer, Director of the North Carolina Department of Health and Human Services Office of Rural Health, traced the history and mission of the Office—the first state entity in the nation created to focus on rural and underserved communities.

Sauer highlighted the scale and complexity of the challenge in North Carolina, where 28.4% of residents—nearly 3 million people—live in rural areas across 78 counties from the mountains to the coast. She noted that these communities face growing strain, particularly as rural hospitals anticipate significant Medicaid cuts under H.R.1.

She outlined the Office of Rural Health’s core programs, including community health grants, the North Carolina Farmworker Health Program, the NC Medication Assistance Program, and Placement and HPSA Services, which supports provider recruitment and designates health professional shortage areas.

Sauer also described efforts to recruit and retain nurses, including the North Carolina Nurse Initiative, which offers qualifying registered nurses and clinical nurse specialists student loan repayment in exchange for providing primary care in eligible outpatient settings serving high-need populations in shortage areas.

Looking ahead, Sauer shared initiatives aimed at advancing North Carolina’s rural health priorities. These include building community care network “hubs,” expanding primary care and prevention models, integrating behavioral health services, strengthening a resilient rural workforce, ensuring fiscal sustainability, and modernizing care delivery through digital-forward solutions.

“I cannot tell you how important partnership is across our region,” Sauer said. “North Carolina has a lot of assets to bring to bear if we decide to work together. I always compare it to going to supper—someone brings the salad, someone the main dish, someone dessert. But if everyone doesn't offer something or brings the same thing, we miss big opportunities. We have to decide we’re in this together.”

Poster Session Shares Partner Research

A poster session shared research and projects spanning a broad range of focus areas, including:

• Bringing healthcare screenings to rural worksites to serve uninsured populations (ɫ��ֱ�� Global Health Institute)
• Improving administration of care delivery to rural veterans (the Durham Center of Innovation to Accelerate Discovery and Practice Transformation)
• Advancing nurse-led systems to prioritize health among unhoused people (UNC’s Gillings School of Global Public Health in partnership with Burke County Public Health)
• Nurse-led chronic pain management in rural areas (Wake Forest University School of Medicine in partnership with AdvocateHealth)
• Planning for a perinatal substance use disorder referral system in Eastern North Carolina (East Carolina University)
• A community-engaged diabetes amputation prevention program intervention in rural Appalachia (ɫ��ֱ�� Health)

Interested in rural health? Visit the Interdisciplinary Hub for Rural Health Equity at ɫ��ֱ�� University and join a Community of Practice meeting.