Rural nurses are known for doing a little bit of everything.
On any given shift, a nurse in a rural hospital may assist with a newborn delivery, stabilize an emergency patient, and provide comfort to someone nearing the end of life. With smaller teams and fewer resources, rural nurses must be ready to care for nearly anything that comes through the door.
For new graduates, stepping into that environment can be daunting – especially when they may be the only new nurse in the hospital. Unlike large health systems where cohorts of graduates start together, rural facilities often hire just one or two new nurses each year. That means many early career nurses are learning the realities of practice without a peer group navigating the same transition beside them. The learning curve can feel steep – and isolating.
"You’re the pharmacy, you’re security, you’re the ER. I might have a 6-month-old with RSV; a 90-year-old that’s on hospice; a 30-year-old that just got their gallbladder out; and I need to know all of those different types of patients and how to care for them."
Programs like the Iowa Online Nurse Residency Program are helping change that by connecting new nurses across rural hospitals and building a community of support. Today, the program is led by Nicole Weathers, DNP, RN, NPD-BC, who experienced the realities of rural nursing firsthand early in her career.
The reality of rural nursing
Born and raised in rural Iowa, Weathers began working in a critical access hospital early in her nursing career – and immediately realized there was a lot to learn.
“It was not what I experienced in nursing school by any means,” she said. “A lot of my clinical training was in large, urban hospitals, and it was very different.”
As a rural nurse, Weathers says, you’re a jack of all trades. Bigger systems might have specialized teams to manage a coding patient or a security issue. At a critical access hospital, it’s all you.
“You’re the pharmacy, you’re security, you’re the ER,” she said. “I might have a 6-month-old with RSV; a 90-year-old that’s on hospice; a 30-year-old that just got their gallbladder out; and I need to know all of those different types of patients and how to care for them. Whereas in an urban hospital, you might be on a pediatric floor that specializes in GI, and that’s what you do all day, every day.”
Weathers describes it as high autonomy, high responsibility. “There’s no one coming to do this for you – I don’t think rural nurses get enough credit for the breadth of knowledge they need to have,” she said.
When you’re the only one learning
The transition from nursing school to clinical practice is widely recognized as one of the most challenging periods in a nurse’s career. Many new graduates report feeling a gap between what they learned in the classroom and the complexities of real-world patient care.
In rural settings, a new nurse may be the only person on their unit experiencing those early career challenges. Without a cohort of peers, professional isolation is a significant risk.
Describing the experience of a new graduate, Weathers says it can feel like, "Some of my colleagues may have been doing this longer than I’ve been alive. I feel like I’m the only one who is struggling – everyone else seems to know what’s going on, and I don’t have anyone at the same level as me.”
Building connection across distance
Recognizing the importance of peer support, the Iowa Online Nurse Residency Program was designed with small and rural healthcare organizations in mind. What began in Iowa has grown into a nationally recognized model for supporting nurses during the critical transition from student to practicing professional.
Launched in 2014, the Iowa Online Nurse Residency Program is the nation’s first fully online, evidence-based transition-to-practice program designed specifically to support new graduate nurses, particularly those entering rural and underserved communities.
Today, the program serves more than 50 healthcare organizations across 13 states and has supported more than 5,000 new nurses as they begin their careers.
The program brings new nurses together from across hospitals and health systems through a competency-based online curriculum. Participants engage in structured learning modules, monthly cohort discussions, and professional development experiences that support the transition from student to practicing nurse.
The program’s impact has also drawn national recognition. In 2025, the Iowa Online Nurse Residency Program was named an Edge Runner by the American Academy of Nursing, an honor awarded to nurse-led innovations that demonstrate measurable improvements in care delivery, workforce outcomes, and health equity.
Through shared discussions and collaborative learning, new nurses from different hospitals can connect with others who are experiencing the same challenges and milestones. They can exchange perspectives, reflect on clinical experiences, and realize that the uncertainties of the first year are common across settings.
Over time, those conversations help build both clinical confidence and professional belonging.
Strengthening the future of rural nursing
Rural healthcare systems depend on nurses who are capable, adaptable, and deeply connected to the communities they serve. But preparing nurses for those roles requires more than just clinical training.
Programs like the Iowa Online Nurse Residency Program are helping rural health systems rethink how that support can be delivered, using technology, collaboration, and peer learning to ensure that new nurses do not face the challenges of their first year alone.
