Nurse workforce change and metropolitan medically underserved areas in the United States

(2025) 25:80 Bowser et al. BMC Health Services Research https://doi.org/10.1186/s12913-025-12228-4 BMC Health Services Research Open Access RESEARCH Nurse workforce change and metropolitan medically underserved areas in the United States Diana Bowser1*, Kaili Mauricio1 and Brielle Ruscitti1 Abstract Background The continued healthcare crisis in the United States (US) is worrisome, especially as workforce shortages, particularly for nurses, are highlighted, often in some of the highest need areas. As the need for healthcare services grows, especially for services that nurses can deliver, the inability to meet those needs exacerbates existing disparities in access to care and can jeopardize the quality and timeliness of healthcare delivery in underserved communities. Prior investigations have used varying definitions to describe underserved, under-resourced, rural, or health professional shortage areas to examine the relationship between these areas and workforce shortages. Therefore, this study examines the relationship between changes in the nursing labor force changes and metropolitan medically underserved areas (MUA), defined by Health Resources and Services Administration (HRSA). Methods Secondary data were utilized to conduct descriptive and regression analyses of the nursing workforce population in metropolitan statistical areas from 2012 to 2022. The key outcome variable for the analyses was nurse workforce change per 10,000 population. Occupational Employment and Wage dataset from the Bureau of Labor Statistics was used to determine the number of nurses employed, at the level of the metropolitan statistical area from 2012 to 2022. The Index of Medical Underservice was extracted for each MUA from HRSA and geographically weighted to the metropolitan area. Results The results of descriptive trends for nursing professions show that all nursing occupations reviewed have experienced positive change over both five- and ten-year periods. However, the results of nurse change models show that neither the change in Registered Nurses nor Nurse Practitioners is correlated with medically underserved areas. Conclusions These results emphasize the need for adaptive strategies in the nursing workforce to respond to the evolution of healthcare requirements over time. The findings from this study suggest the need for careful planning in workforce policy and education to grow the nurse workforce needs to meet evolving healthcare needs effectively. Keywords Nurse workforce, Medically underserved areas, Workforce retention, Nurse mobility, Nurse occupation growth *Correspondence: Diana Bowser 1 William F. Connell School of Nursing, Boston College, 140 Commonwealth Ave, Chestnut Hill, MA 02467, USA Introduction Access to healthcare and healthcare infrastructure varies widely across the United States (US), illustrated by a range of inequities in the US healthcare system, including but not limited to nursing workforce shortages. While nurses became the nation’s “healthcare heroes” during the COVID-19 pandemic, a number of factors, including © The Author(s) 2025. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. Bowser et al. BMC Health Services Research (2025) 25:80 COVID-19 exposure, personal protective equipment availability, fear, depleted resources, and family and personal reasons, caused many nurses to leave the profession [1–4]. Nursing homes and other long-term care facilities were especially impacted by the nursing shortage during the COVID-19 pandemic [5]. While the COVID-19 pandemic highlighted the nurse shortage, trends in nursing turnover had begun to increase prior to the pandemic, due to demographic factors, insufficient staffing, a lack of experience, lack of nursing schools in high-need areas, low salaries, and low job satisfaction [6–8]. Many of these factors were exacerbated in areas that were already highneed and medically underserved. Medically underserved areas (MUA), defined by the Health Resources and Services Administration (HRSA), are identified as geographic areas and populations with a lack of access to primary care services [9]. MUAs included in this analysis are shown in Annex A1. MUAs are identified either through predetermined criteria (density of primary care physicians per 1,000 people, proportion of residents living below the federal poverty level, percentage of the population aged 65-years and older, and the area’s infant mortality rate) or via a discretionary process based on unique circumstances or considerations [9]. MUAs tend to be located in areas with a high number of patients with more unique or complex medical needs and delayed or forgone care, resulting in barriers in access to care for many patients [10–12]. While research shows that many of the healthcare needs in MUAs can be addressed through primary care services [13], which can be increasingly delivered by nurses [14, 15], to the authors knowledge, there have been no studies examining the number of nurses working in and moving to MUAs, as defined by the HRSA. The continued healthcare crisis in the US is worrisome, especially as workforce shortages, particularly for nurses, are highlighted, often in some of the highest-need areas. While some studies have shown a rebound in nursing workforce following the COVID-19 pandemic in 2022 and 2023 [16], the US Department of Health and Human Services has projected seven states will have a shortage of RNs in 2030, with four of these states having a deficit of 10,000 nurses or more [17]. Georgia and Minnesota report the highest rates of shortages, with both states having nursing shortages of over 25% [5]. Furthermore, as of 2020, the South, as defined by the US census, had the lowest per-population availability in the nation for certified nurse-midwives, and the highest maternal mortality [18]. Areas with nursing shortages tend also to have similar patterns with other health related indicators like infant mortality. Alabama, with one of the highest infant mortality rates in the US, faces severe nurse and physician shortages, resulting in a 9% loss of labor and Page 2 of 9 delivery services from 2004 to 2014 [19, 20]. Additionally, research on health (...truncated)