An integrative review of new nurse practitioners’ experiences in rural healthcare practice

Introduction: A maldistributed primary care workforce and disparities in health outcomes are ongoing concerns for rural populations across the globe. Nurse practitioners (NPs) offer a promising solution for mitigating rural healthcare inequities by reducing shortages and improving access to primary care. The NP workforce is the fastest-growing sector of primary care providers in the USA. NPs are more likely than their physician colleagues to spend careers in rural and underserved settings practicing in isolation from other providers with higher rates of turnover. An indistinct understanding of rural NPs’ early career experiences informs the need for a critical synthesis of the literature and key future recommendations. This integrative review aimed to analyze and synthesize various types of empirical reports and theoretical papers about new NPs’ experiences in rural primary healthcare practice, identify current literature gaps, and discuss implications for education, policy, and further research. 
Methods:  Whittemore and Knafl’s integrative method was used to inform the selection, review, and analysis of the literature. Search keywords were based on the Population, Effect of Interest, Measure, Study Design, Setting framework: (1) population (primary care NPs); (2) effect of interest (early career phase in a rural context); (3) measure (NP perspectives about their experiences); (4) study design (empirical, theoretical); and (5) setting (rural USA and countries with a similar healthcare system and NP workforce, such as Australia, Canada, Ireland, Netherlands, and New Zealand). Four key databases (PubMed, Embase, Web of Science, CINAHL) were searched, followed by manual-searching of reference lists to identify relevant empirical and theoretical literature; no time delimitation was applied in the search. 174 sources were scanned. Data were iteratively compared, and significant patterns were extracted and organized into thematic clusters.
Results: The literature search yielded five studies that met the eligibility criteria, including three phenomenological studies, one descriptive qualitative study, and one descriptive quantitative study. Three themes emerged: (1) the trajectory of early career practice for rural NPs; (2) commitment and persistence of new rural NPs; and (3) adaptive and maladaptive early career factors for rural NPs.
Discussion and Conclusion: This review included articles published in the USA, although emergent themes may contribute to global knowledge about early career experiences in rural settings where advanced practice nurses are used. This review reinforced that NPs as a distinct professional population are underrepresented in rural workforce research, particularly during their early career phases. Scholarly literature about new rural NPs emphasized clinical preparedness and competence, workplace recruitment incentives, transition-to-practice experiences, and the importance of mentoring and professional networks. However, findings are limited primarily to the first year of practice. 
Future research priorities include exploring the ways to support rural NPs’ well-being during the transition-to-practice phase, the barriers and facilitators to their job satisfaction by career stage, and factors contributing to burnout and turnover. Further exploration of community contexts and adaptive processes are indicated to inform meaningful NP educational refinements and effective retention policies. Understanding the experiences of rural NPs who are newcomers to rural life should also be explored.
Keywords: early career, integrative review, new nurse practitioners, rural healthcare practice.