Next up in our Cancer Care series for #BreastCancerAwarenessMonth, we are excited to share this article about the specific challenges in rural healthcare and how thoughtful design can offer solutions.

 

Jim Albert, HCM Principal and Healthcare Market Sector Leader, interviewed Elizabeth Johnson, PhD, MS-CRM, RN, an Assistant Professor at Montana State University’s Mark & Robyn Jones College of Nursing in Bozeman.

 

Q: What unique challenges do rural healthcare facilities have?  

The individuals who live in rural areas often think about “rurality” more from a cultural perspective and less from a geographical perspective. The challenges they face reflect that. Take, for example, isolation. In rural nursing theory, isolation isn’t just about being physically far from other towns—it’s more about the professional isolation that comes from working in these remote settings. If you’re a nurse practitioner working in a healthcare provider shortage area, you might be the only one around, and that can feel pretty isolating. These practitioners have to be incredibly independent and confident in their clinical judgment.

And it’s not just about people—it’s also about things like supply management. Getting resources in and out can be tough, and the impacts can be very broad. On a similar note, rural healthcare facilities might also face economic isolation because they are often tied to the success of a single economy, such as agronomy. If a town’s industry is doing well, typically the healthcare system will also do well. But if it’s struggling, the healthcare system tends to feel that impact pretty quickly. There just isn’t a lot of economic diversity to act as a buffer, which makes rural healthcare especially vulnerable.

Another unique challenge that rural communities face is that they are aging, which creates some unique care delivery challenges like managing chronic disease, addressing mobility issues, and coordinating interfacility transfers. This also relates back to the previous point about the economy, because it means that reimbursement rates are lower, and there isn’t a lot of payer diversity for facilities to offset that and stay financially viable.

Something else we often hear about in rural areas has to do with health beliefs. If you ask someone what “healthy” means to them, it’s not necessarily always about lab results or checkups but whether they can work and take care of their family. They see health as tied to their ability to fulfill those traditional roles and that shapes how they engage with the healthcare system.

I had a patient going through cancer treatment who told me that his role as the church handyman was his way of serving others. He saw his ability to lead and help in this way as directly tied to his health. As his illness progressed, simple tasks started taking him longer than usual and that really shook him. It wasn’t just about his physical health, it was about the shift in seeing himself as someone who helped others to someone who needed help.

Q: How can people, designers, architects, engineers, etc., help rural healthcare facilities balance limited resources with the need to provide comprehensive, high-quality care?

Instead of saying, “limited resource,” I would say, “How do we elevate these communities by building on the strengths and resources that they do have?” That kind of language matters because calling them “limited” can be belittling and can lead to hesitancy and mistrust about bringing design teams in. This is where participatory codesign comes into play. And it’s not just doing tabletop exercises or putting sticky notes on a Miro board; it’s also about understanding when we have a participatory framework that we’ve published.

We start by looking at their Community Health Needs Assessments. Something we’ve heard over and over again is that design teams will come in and ask questions that maybe are considered redundant of what the community has already shared, which can be really frustrating.

Something that we’ve really championed at Montana State University is having embedded exposure in the community. For us, this means really spending time in and around the community. Sometimes that’s looked like literally sitting for hours to watch who’s coming in at different times, observing the flow of the day, and asking ‘What does a rush look like?’

How we define resources might look very different, too. For example, one facility might not be equipped to provide a specialty service, but they’ve built a reputation for excellence in another, so neighboring communities might send their patients there for that specialty need. It’s a great example of how rural communities already share resources in effective ways.

If there’s something that design teams can lean into, it’s strengthening the technological infrastructure. I would strongly encourage designers to focus on the typical 10-to-15-year renovation cycle. We’re really looking at 20 to 25 years with these facilities, so sometimes it may not be the flashiest, most cutting-edge solution, but it could be something that is reliable and widely used.

Q: In what ways can thoughtful design improve access to healthcare for rural communities, whether through physical infrastructure, technology integration, or community connection? Essentially, how can the built environment be improved through design?

Thoughtful design can focus on how to build third-place access to healthcare. We meet a lot of the hierarchy of needs from social connection, and we can use the built environment to improve community networking, which is another trait of rural communities.

I would also love to see us rethinking how and where we offer access to healthcare in rural communities – like in schools, post offices, or grocery stores. We actually heard in our research that people often found out about available healthcare services on any given week just by chatting with others at the store. Local radio is another powerful tool for spreading the word. Beyond that, what if we reimagined rural healthcare spaces as community hubs? Could we create coworking spaces in these facilities? Not just as a place for internet access, but to help working-age residents get services like vaccines, sports physicals, and other prevention offerings. Could we design larger parking lots to accommodate mobile imaging units or simulation training? Even simple things like covered awnings could make a big difference. I think it’s time to go back to basics and really think about how these spaces can serve the whole community.

Other things I would love to see from design teams are a higher degree of attention to flexible adaptive space in these facilities, which will help us get past the 10-to-20-year marks if these facilities don’t have the capital to do the full overhauls. This could help meet the needs of a changing community and changing landscape.

Q: Looking ahead, what new advances or practices are likely to emerge in rural settings?

One area that we’re incredibly excited about right now is nurse-led integration, technology integration, and appraisal of tech adoption. Nurses are largely the backbone of rural care delivery, but they haven’t always had a seat at the table when it comes to designing the tools and systems they use every day. We’d love to see boards of nursing offer continuing education that focuses on design thinking and tech innovation so that nurses are equipped, aware, and empowered.

I’m also very proud of our architects and engineers in rural facilities because they had a huge challenge, particularly during the pandemic, to keep the supply chain going. I think that there’s a lot to learn also from our architect and engineering colleagues regarding best practices related to semi-movable structures for healthcare.

Another area we’re really excited about is exploring sustainable built environments. For example, here in Montana, we’re looking into using rammed earth as an approach to building structures. We know that a lot of our built environment materials just cannot withstand the degree of variability in climate, especially its impacts on rural communities. And we know we’re not alone in that.

As we start looking at climate change, we’re also very cognizant of natural disaster planning and emergency response. Rural communities are already highly attuned to disaster planning, so we’re seeing a lot of new advances and practices around designing for sustainability and emergency response.

Elizabeth Johnson, PhD, MS-CRM, RN

Elizabeth Johnson is an Assistant Professor at Montana State University’s Mark & Robyn Jones College of Nursing in Bozeman, where she examines the juncture of community based participatory design, clinical system infrastructure appraisal, and innovative research approaches to the intersection of healthcare and technology development. Her teaching portfolio includes Design of Healthcare Delivery Systems, a dynamic interprofessional graduate course that unites nursing and engineering students to solve real-world challenges in patient care quality and system efficiency.

Elizabeth’s research focuses on advancing digital health technologies to enhance safety and monitoring in clinical trials. Her work has earned funding from the NIH, the American Nurses Association, Genentech Innovation Fund, the National Science Foundation’s I-Corps program, and the MSU/U.S. Economic Development Administration. She is also a member of MIT’s Blueprint Engine–Tough Tech program, where she contributes to the development of high-impact healthcare innovations.

A nationally recognized leader in healthcare design and clinical research nursing, Elizabeth serves as Chair of the Research Committee for the International Association of Clinical Research Nurses, President-Elect of the Nursing Institute for Healthcare Design, Health Systems Advisory Board member for the Coalition for Health AI, and served with the American Nurses Association Innovation Advisory Committee for Technology and Medical Devices.

Before entering academia, Elizabeth held roles as a clinical research nurse, trial manager, and global early-phase development leader across hospital and industry settings supporting both pediatric endocrinology and adult oncology programs.

Listen to Elizabeth’s podcast, powered by the Nursing Institute for Healthcare Design, which invites architects, engineers, interior designers, and providers to share their powerful insights and perspectives on how healthcare facilities and the systems they held within affect our daily lives.

Jim Albert, AIA, ACHA, LEED AP

Jim Albert serves as Market Sector Leader of the Hord Coplan Macht healthcare team providing vision and oversight for a wide range of healthcare projects.  As a Lean trained professional, Jim is committed to helping clients imagine a better way of delivering healthcare services.  He believes that a well-designed healthcare facility can improve the patient, family and staff experience while making the workflow more efficient and effective.  Jim’s work focuses on designing complex projects within hospital and ambulatory settings.  He has spoken and written nationally on the importance and impact of effective healthcare design.

Explore more of our Cancer Care Series:

Part I: Bridging the Gap: Designing for the Full Cancer Journey