Cultivating a rural nursing workforce: the impact of rural vs. urban education on nursing students’ intentions for rural practice in Nepal

Abstract Background Rural–urban maldistribution of health professionals continues to widen health inequities, particularly in low- and middle-income countries (LMICs). In Nepal, nurses are central to frontline care in remote communities, yet “urban pull” forces and structural constraints undermine rural recruitment and retention. This study examined how training at a rural-embedded institution—Karnali Academy of Health Sciences (KAHS)—may shape final-year nursing students’ intentions for rural/remote practice and the barriers they anticipate. Methods We used a two-site qualitative descriptive design with an exploratory orientation. Semi-structured interviews were conducted with 22 final-year female nursing students: 11 from an urban tertiary institution and 11 from KAHS. A codebook-style applied thematic analysis was undertaken. Ajzen’s Theory of Planned Behaviour and a structural intervention lens guided interpretation of how institutional context may influence beliefs underpinning rural-practice intentions. Results Five themes captured students’ accounts: (1) rural immersion and emerging rural commitment; (2) experiential learning beyond the books; (3) the relational pull of community-centred care; (4) perceived urban–rural inequities and curriculum gaps; and (5) gendered and professional barriers to rural practice. Most KAHS participants—including several of urban origin—described strong intentions to begin their careers in rural/remote settings, whereas most urban-site participants anticipated urban employment. However, anticipated constraints—especially safety concerns, social isolation, professional/academic isolation, and limited career development pathways—were repeatedly described as factors that could weaken the feasibility and sustainability of rural practice. Conclusion Rural-embedded education may strengthen intentions to serve in rural areas by reshaping how students evaluate rural work (attitudes), social expectations (subjective norms), and the feasibility of rural service (perceived behavioural control). Yet intention formation occurs alongside persistent gendered and structural barriers. Longitudinal research is needed to track post-graduation trajectories and to identify multi-component strategies that translate rural intention into durable rural retention. Clinical trial number Not applicable.