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| REVIEW ARTICLE |
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| Year : 2020 | Volume
: 25
| Issue : 2 | Page : 67-78 |
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Recruitment and retention of healthcare professionals in rural Canada: A systematic review
Savanna Heidi Koebisch, Jacqueline Rix, Michelle M Holmes
School of Chiropractic, AECC University College (Formerly Anglo-European College of Chiropractic), Bournemouth, England
| Date of Submission | 18-Jun-2019 |
| Date of Decision | 26-Sep-2020 |
| Date of Acceptance | 22-Jan-2020 |
| Date of Web Publication | 28-Mar-2020 |
Correspondence Address:
MChiro Savanna Heidi Koebisch
School of Chiropractic, AECC University College (Formerly Anglo-European College of Chiropractic), Bournemouth
England
 Source of Support: None, Conflict of Interest: None  | 9 |
DOI: 10.4103/CJRM.CJRM_43_19
Introduction: This review explores a pertinent issue for healthcare professionals and recruiters alike: which factors are most important in the recruitment and retention of these professionals in rural practice in Canada. Existing research concentrates on specific factors or focused populations. This review was created to explore multiple factors and a wider population of healthcare professionals, including chiropractors, osteopaths, dentists and physiotherapists.
Methods: A literature search was carried out on four databases. Data from included studies were extracted, and thematic analysis was conducted on relevant findings. The quality of individual studies was assessed, and then themes were evaluated for overall confidence based on four components, using the Confidence in the Evidence for Reviews of Qualitative Research.
Results: One quantitative and four qualitative articles were identified, all of which targeted physicians. Five themes – Personal/family matters, Community factors, Professional practice factors, Professional education factors and Economic factors – were generated in two domains, recruitment and retention. Forty major codes were generated through axial coding of open codes. Codes included attraction to rural lifestyle, recreational activities, Scope of practice, rural training and incentives. Scope of practice was deemed very important as a factor of recruitment, as was attraction to rural lifestyle. Incentives were found to be of little importance in influencing the recruitment of healthcare professionals, and even less important for retention.
Conclusion: Wide scope of practice and attraction to the rural lifestyle were considered the most important for recruitment and to a lesser extent, retention, among the five papers studied. A lack of research was determined in the realm of factors influencing the recruitment and retention in healthcare professionals other than medical doctors in Canada. Therefore, it is recommended that further such studies investigate specific healthcare professionals.
Résumé
Introduction: Cette revue de synthèse se penche sur un enjeu pertinent pour les professionnels de la santé et les recruteurs; quels sont les facteurs les plus importants du recrutement et de la rétention de ces professionnels en pratique rurale au Canada? La recherche actuelle se concentre sur des populations ou des facteurs précis. La présente revue de synthèse étudie de multiples facteurs ainsi qu'une vaste population de professionnels de la santé, y compris chiropraticiens, ostéopathes, dentistes et physiothérapeutes.
Méthodologie: Une recherche a été effectuée dans 4 banques de données de publications scientifiques. On a extrait les données des études incluses, et on a effectué une analyse thématique des constatations pertinentes. La qualité de chaque étude a été évaluée, puis les thèmes, à l'aide de la méthode CERQual (Confidence in the Evidence for Reviews of Qualitative Research) pour leur confiance générale en fonction de 4 éléments.
Résultats: Un article quantitatif et quatre articles qualitatifs ont été relevés, et ils ciblaient tous les médecins. Cinq thèmes, soit affaires personnelles ou familiales, facteurs communautaires, facteurs liés à la pratique professionnelle, facteurs liés à l'éducation professionnelle et facteurs économiques, ont été générés dans les domaines-du recrutement et de la rétention. Quarante codes majeurs ont été générés par codage axial des codes ouverts. Ces codes étaient attirance pour le mode de vie rural, activités récréatives, champ de pratique, formation rurale et incitatifs. Le champ de pratique a été jugé être un facteur très important du recrutement, tout comme l'attirance pour le mode de vie rural. Les incitatifs se sont révélés avoir peu d'influence sur le recrutement des professionnels de la santé, et encore moins sur la rétention.
Conclusion: Dans les cinq articles à l'étude, un large champ de pratique et l'attirance pour le mode de vie rural étaient considérés être les facteurs les plus importants du recrutement et, dans une moindre mesure, de la rétention. On a déterminé que la recherche était insuffisante dans le domaine des facteurs qui influent sur le recrutement et la rétention des professionnels de la santé autres que les médecins au Canada. Il est donc recommandé d'effectuer d'autres recherches sur des professions médicales précises.
Keywords: Canada, primary care, recruitment, retention, rural health services
Mots-clés: Canada, soins de première ligne, recrutement, rétention, service de santé ruraux
How to cite this article:
Koebisch SH, Rix J, Holmes MM. Recruitment and retention of healthcare professionals in rural Canada: A systematic review. Can J Rural Med 2020;25:67-78 |
How to cite this URL:
Koebisch SH, Rix J, Holmes MM. Recruitment and retention of healthcare professionals in rural Canada: A systematic review. Can J Rural Med [serial online] 2020 [cited 2023 Mar 26];25:67-78. Available from: https://www.cjrm.ca/text.asp?2020/25/2/67/281515 |
| Introduction | |  |
The World Health Organization encourages the establishment of sustainable health systems and promotes retention of health workers in underserved areas.[1] Although Canada does not have the shortage of health workers that some developing countries demonstrate, the rural health system may not be sustainable. To transform this shortage into a sustainable structure, recruitment and retention strategies should be evaluated. Multiple factors influence the recruitment and retention of health-workers in rural Canada, including personal, economic, professional, education, family and community.[2],[3] Previous research focused on specific elements.[4],[5],[6],[7] This review aimed to conduct a broader synthesis by reviewing multiple factors of recruitment and retention.
| Methods | | |
Search strategy
Subject-specific electronic databases including PubMed, Medline Complete, Index of Chiropractic Literature and Cochrane Library were searched. Hand-searching and “snowballing” were performed. Key terms were combined with Subject Heading Terms, relating to recruitment, retention and healthcare professionals. Study selection was pre-determined by using inclusion and exclusion criteria and was screened for eligibility accordingly. Both qualitative and quantitative papers were eligible [Table 1]. Only English language primary research conducted in Canada was included. Studies were chosen if they investigated multiple factors affecting recruitment and retention. Exclusively Francophone and Indigenous culture-specific studies were dismissed, as they may not be generalisable. Study participants were healthcare professionals with diagnostic capabilities such as medical doctors, chiropractors, dentists, osteopaths and physiotherapists practising in rural Canada. All age groups, genders and career stages were considered applicable. Specialisation was not an exclusion criterion.
Data extraction, quality appraisal and synthesis
Study and participant characteristics were extracted and tabulated [Table 2]. An inclusive extraction of findings was conducted and analysed using thematic analysis. Concepts were combined, resulting in the axial coding of open codes. Themes, sub-themes, major and minor codes were generated. Major codes represented the factors influencing recruitment and retention. Minor codes were the individual impact of these factors on recruitment and retention, respectively. These were scored high or low, based on frequency, prevalence in text and description of importance.
Overall study quality was judged using a combination of critical appraisal checklists, assessment of bias and limitations of study and participant characteristics.[8],[9] Themes were assessed for overall confidence using the Confidence in the Evidence for Reviews of Qualitative Research (CERQual) approach.[10] Each theme was assessed based on methodological limitations, relevance, coherence and adequacy of data. A final table was developed summarising the CERQual assessments [Table 3] and [Table 4].{Table 1}{Table 2} | Table 3: Confidence in the Evidence for Reviews of Qualitative Research Qualitative Evidence Profile - Recruitment
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 | Table 4: Confidence in the Evidence for Reviews of Qualitative Research Qualitative Evidence Profile - Retention
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| Results | | |
Study selection
A total of 139 papers underwent a screening process. After 28 duplicates were removed, 111 papers remained. A further 102 studies were excluded based on title/abstract screening and inclusive and exclusive criteria [Table 1]. A full text assessment led to the rejection of four papers. One of these papers focused on a culturally specific cohort, and the remaining three addressed specific factors. Five papers fit the review's pre-determined inclusion and exclusion criteria[2],[3],[5],[6],[7] [Figure 1].
Study characteristics
Four qualitative studies and one quantitative study were identified.[2],[3],[5],[6],[7] All studies examined physicians who were in rural practice. There were no studies involving other healthcare professionals that fit our criteria. The physicians in these studies either practised family medicine or had specialised. The qualitative studies used varied, with three studies using pre-determined questions to interview their subjects[2],[5],[6] and one basing their method on the grounded theory.[3] Two qualitative studies assessed both recruitment and retention,[2],[3] one explored factors of recruitment,[6] with one focused on retention.[5] Cameron et al. also interviewed, observed and retrieved information from staff members, spouses and community members.[5] The quantitative study by Chauban et al. included both recruitment and retention in their survey.[7] The quantitative study contained the largest sample size, surveying 642 participants.[7] The analysis varied among papers. Descriptive text, numerical ranking and percentages and the number of communities out of four were used.
Synthesis of results
A total of 40 factors influencing recruitment and retention were allocated to 5 common themes, across 2 domains. There were 13 professional practice factors, 12 personal and family factors, 10 community factors, 3 professional education factors and 2 economic factors. The factors either had an impact on recruitment, retention or both. [Table 5], [Table 6], [Table 7], [Table 8], [Table 9] illustrate examples of the overlap of common factors among papers and list the weighting of importance of each paper in their respective outcome measurements.
Personal/family factors
Attraction to the rural lifestyle was one of the main factors deemed important for recruitment. It was the second most influential recruitment factor for both the study by Chauban et al. and Wasko et al.[3],[7] Eighty-three per cent of the younger physicians, compared to 81% of older physicians, considered liking the rural lifestyle as an important factor for recruitment.[7] This factor was also important for retention, with Wasko et al. ranking it fifth of twenty factors investigated.[3] However, in comparison to recruitment, it was less influential, which was a common pattern among papers.
Community factors
Recreational and leisure activities were nearly equal in importance for recruitment and retention. According to Asghari et al., “those who enjoyed nature and being outdoors found rural practice to be attractive.”[2] Wasko et al. ranked its importance as #5.[3] By frequency, 71% of younger physicians and 60% of older physicians in the study by Chauban et al. mentioned this.[7] Four of 4 communities in Cameron et al.'s study found this important as a factor of retention.[5]
Professional practice factors
The most frequently mentioned factor was scope of practice, appearing in each paper either under recruitment, retention or both. In terms of recruitment, this factor overlapped in four studies. Two papers listed this as their most influential factor. In the study by Chauban et al., 86% of young physicians and 83% of older physicians found this important.[7] Of twenty total factors that Wasko et al. looked at for retention, the ability to practice full-scope medicine was the second most important.[3]
Professional education factors
In one study, rural experience in training ranked as the seventh most important for recruitment in both younger and older generation practitioners.[7] Seventy-one per cent of younger physicians rated this factor positively with regards to recruitment, compared to 40% of older physicians. The higher percentage of rural rotations and experience in training in the younger generation also correlated with a higher satisfaction with their preparedness for rural practice. Physicians who had completed rural rotations were more likely to have received incentives. They also listed preference for rural practice as their most influential factor for choosing rural practice. On the contrary, those physicians who had not completed rural rotations noted the wide scope of practice as their primary reason.[2] Continuing professional development was mentioned multiple times as a factor for retention.
Economic factors
Four of the papers rated incentives (financial and/or non-financial) as not effective in recruiting healthcare professionals. Eight per cent of participants in the study by Wasko et al. noted the benefit of bonuses or incentives for recruitment.[3] While Asghari et al. found disagreement on the effectiveness of incentives for recruitment, they stated that incentives were even less influential on retention.[2] Wasko et al.'s economic factor findings were similar to those of the above mentioned study, with incentives being their least important factor for retention.[3] Incentives were of greater importance to younger versus older physicians.[7]
| Discussion | | |
This review aimed to explore the most important factors in the recruitment and retention of healthcare professionals in rural practice in Canada. Five eligible studies were included, and 40 factors were identified across the 2 domains of recruitment and retention. This systematic review of the literature determined attraction to the rural lifestyle, recreational activities, scope of practice, rural training and incentives as discussion worthy.
Personal and family
A prominent influencer with regard to personal and family factors is attraction to the rural lifestyle. This can be very difficult to manage from a recruitment point of view since it is personal preference. Advertisement campaigns such as Travel Alberta's “Remember to Breathe,” can be crucial in promoting the attractiveness of a certain location.[11] Government-endorsed campaigns are another strategy to promote the advantages of rural lifestyle.[12]
Community
The availability and quality of recreational activities in rural areas is an important community-based factor for both recruitment and retention of physicians. Canadians are known to have an affinity for the outdoors.[13] Three of four households disclosed a family member participating in outdoor activities close to home.[14] Health professionals, who are aware of the benefits of exercise, will be even more likely to engage in outdoor activities, making recruitment and retention an ideal match for this population.
Professional practice
In terms of recruitment, factors of professional practice were considered very important in this review, especially scope of practice. As a general physician in rural areas, additional skills must be enhanced. These areas of medicine include general anaesthesia and surgery.[15] Wasko et al. state: “it is in a rural setting that full-scope family medicine is most often practised.”[3] Specialists, on the other hand, found rural practice patient populations simply too small to support a practice. This is reflected by the Canadian Medical Association (CMA), which states that in 2015, 14% of Canada's family physicians practised in rural locations, compared to only 2% of the specialists.[16] Specialisation and sub-specialisation is a growing trend among medical students.[17] This poses the risk of more new graduates congregating in urban centres, which could create a surplus in these areas and increase the shortage in rural locations.
Professional education
Our review also explored the impact of professional education, such as rural training, on recruitment. Based on the pattern identified by Chauban et al., one can devise that many of the participants of papers in this review did not have rural training.[7] Scope of practice being the number one factor for recruitment in our review may not be entirely accurate, as it depends on the participant characteristics that were not mentioned by some of the examined studies.
Though our review found incentives to have a minimal effect on retention, strategies encouraging this are still in place. For example, Alberta has a Retention Benefit Program which offers payments for each year in practice.[18] Incentives had varying degrees of influence on differing participant ages.
Economic
Economic factors were a largely debated finding. Younger physicians were far more likely to find incentives very, or somewhat, important. This may be due to the higher costs of medical school tuition in recent years, leading to a greater need of financial support during their early careers to alleviate their student debt.[7] According to the Graduation Questionnaire National Report, the median amount of debt accumulated directly from medical studies was $94,000.[19] In addition, rural-origin students are more likely to have a higher debt load on entry to medical school, due to the necessary added costs of living away from home.[20]
“The increasing cost of medical education and student debt may decrease physicians' interest in rural practice, leading them to choose a more lucrative urban medical specialty.”[21] Indeed, Canadian family physicians received an average gross of $253,683. Medical specialists however, averaged $349,039.[22]
Bias, limitations and strengths
The factors discussed within our review were but a small sample of the reasons why practitioners choose rural practice. The raw numerical data extracted can be used for further interpretation of correlations.
Each study used their own unique pool of questions. Asghari et al. minimised question bias using the Delphi method to reach consensus regarding interview questions.[2] They piloted the interview on two rural physicians. The other studies did not mention whether they had accounted for question bias. Misunderstood or unanswerable question bias could have occurred in any of the studies, especially in studies researching older generation physicians, where recall bias could appear. Biased reporting was mentioned as a limitation in Wasko et al.[3] The halo effect may have been present in studies that examined financial factors, such as incentives or remuneration.[23] Physicians may have been reluctant to report on the importance of or role of financial factors. Moderation bias may have been present in the study by Wasko et al. since students and residents with a lower educational rank and inexperience in questioning were the interviewers.[3] External validity may have been affected simply by participant involvement in the survey, when participants realised their role in the study, known as the Hawthorne effect.[24]
Due to the heterogeneous outcome measures among the studies, a comparison of the importance of individual factors was difficult. Choosing one representative example of each theme, based on their importance or frequency of appearing in the studies, may have created outcome and reporter bias, influencing the validity of the review. Using only four databases, important studies may have been missed. However, the exploratory and explanatory data design, which combined both qualitative and quantitative data, improved study reliability. The mixed methods approach provided a holistic view of the research topic.
The overall level of evidence gathered in our review, taking both the articles' and review's strengths and limitations into account, is moderately high. Although the studies had minor flaws individually, the results still demonstrated a commonality. Therefore, recommendations could be derived from the data.
Recommendations
Based on the literature, the following recommendations can be established. The effectiveness of retention-benefit programs should be questioned. The connection between rural experience in training and the likelihood of choosing rural practice, should be thoroughly explored. Further exploration of the link between the amount of student debt and the preference of financial incentives for recruitment should be conducted.
Although this systematic review sought to explore factors influencing healthcare professions, no published study looking at additional healthcare professions was found. Thus, the papers in this review, as well as the results, were based solely on physicians with medical training. There is need for further research looking at specific healthcare professionals to gain a deeper understanding of this subject area.
| Conclusion | | |
The ability to practice full-scope medicine was the most important factor in terms of physician recruitment, and to a lesser extent, retention, among the five articles studied. Attraction to the rural lifestyle was also considered important in these realms, but to a slightly lesser extent compared to scope of practice. Our review found a lack of research in terms of factors of recruitment and retention in non-physician healthcare professionals in rural Canada. Further research is recommended in this realm.
Financial support and sponsorship: Work was conducted as part of SHK undergraduate research project.
Conflicts of interest: There are no conflicts of interest.
| References | | |
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| 3. | Wasko K, Jenkins J, Meili R. Medical practice in rural Saskatchewan: Factors in physician recruitment and retention. Can J Rural Med 2014;19:93-8. |
| 4. | Soles TL, Ruth Wilson C, Oandasan IF. Family medicine education in rural communities as a health service intervention supporting recruitment and retention of physicians: Advancing rural family medicine: The Canadian collaborative taskforce. Can Fam Physician 2017;63:32-8. |
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[Figure 1]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9]
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