Introduction
Recruiting and retaining a skilled workforce is a common challenge across remote and rural parts of the world. There are different complex and interconnected factors rooted in the wider socio, political, and economic context influencing a health worker’s decision to start, stay, or leave a job in a remote and rural area [
1]. The research literature includes a vast pool of studies on different factors facilitating or hindering recruitment and retention of healthcare workers to remote and rural areas. These have been described as “pull” and “push” factors. The “pull” factors are those that attract health professionals for a given job/location. The “push” factors are those that influence the health workers not to take a job or to leave a job in a given location [
2].
The three factors most strongly associated with entering a rural job are as follows: (1) a rural upbringing, (2) positive clinical and educational experiences in rural settings as part of undergraduate education, and (3) targeted training for rural practice at the postgraduate level [
3]. A range of factors influencing the decision to stay in or leave a rural job have been identified in the literature for a range of health professions in different countries. These factors include financial and economic considerations (such as remuneration and other benefits) [
4‐
7], professional and organizational issues (including professional development opportunities, workload, and infrastructure) [
5,
8‐
13], social factors (including employment and educational opportunities for other family members) [
8,
14,
15], individual factors [
16,
17], and the characteristics of the local community itself [
4,
6,
18‐
21].
There is a substantial literature proposing and describing interventions taken by different stakeholders to act on this evidence. Interventions can broadly be divided into education policies, monetary incentives, non-monetary incentives, skills substitution, and regulatory policies [
1,
2,
4,
22‐
31]. Although some interventions have shown promise, there is a lack of well-designed studies to measure their short-term and long-term effectiveness in a rigorous fashion [
30,
31]. Particularly, there is very little evidence showing the effectiveness of any specific retention intervention [
2,
32]. However, support exists in the literature for the effectiveness of “bundling” more than one retention intervention [
22,
31,
33].
An additional challenge to successful recruitment and retention is the reality that remote and rural communities all differ from each other [
34], even though many of the challenges in rural health are common around the world [
35]. The realities of rural settings require healthcare providers to be generalists with a specific broad range of knowledge and clinical skills [
36]. The widespread shortages of health professionals mean that gaps may be filled with health professionals who lack the generalist skills and for that reason do not stay. The resulting transience in the workforce adversely affects service quality and patient experience [
37].
In this context, local healthcare organizations in remote and rural areas have few practical tools to guide them in their struggle to recruit and retain personnel. Nevertheless, they face this struggle every day. The purpose of this paper is to describe how The Framework for Remote Rural Workforce Stability was developed, its contents, and how it can be used. The Framework is a strategy designed for rural and remote healthcare organizations to ensure the recruitment and retention of vital healthcare personnel. A strategy is a high-level plan to achieve one or more goals under conditions of uncertainty. Uncertainty refers in this context to the varied and complex research evidence concerning the effects of the different interventions that have been suggested and used in this field of practice, as well as the wider socio, political, and economic context influencing health workers’ job decisions.
Method—the framework development process
The partnership
In the period 2011–2019, an international partnership of academics, human resources professionals, health services administrators, health professionals, and social and cultural development professionals, living and working in northern rural or remote communities in Sweden, Norway, Canada, Iceland, and Scotland, has explored factors related to workforce recruitment and retention in rural and remote environments. We synthesized existing research-based knowledge and practical experience to generate new knowledge from case studies in the respective countries. Throughout the period, the goal was to develop a practical tool to guide remote and rural health organizations towards achieving stability in their workforce recruitment and retention activities.
The setting
The partnership undertook two projects between 2011 and 2019. In the first project entitled Recruit and Retain (2011–2014), funded by EU Northern Periphery Programme 2007–2013, the partnership developed, implemented, and evaluated a variety of initiatives/solutions that were proven to be successful in supporting recruitment and retention in their local communities [
38]. This project also developed a composite seven-step business model [
39] to assist and underpin the recruitment and retention of healthcare professionals in remote and rural areas.
In the second project Recruit and Retain: Making it Work (2015–2019), funded by EU Interreg Northern Periphery and Arctic Programme 2014–2020, the aim was to utilize the seven-step business model and evaluate its performance. However, it became clear early on that the seven-step model was not sufficiently developed to be useful in practical settings. During the project period, the partnership further refined the seven-step model and developed the broader Framework with nine strategic elements and five conditions for success.
Methodology
The move from the seven-step business model to the Framework was based on insights derived from five different case studies, one conducted in each of the partnership countries, and a parallel collaborative Framework development process.
The project was managed collaboratively, with working groups that included representatives from each country. Our initial plan was to create similar local business cases in each partner country as a starting point to try out the seven-step model and design a similar evaluation process to measure and compare outcomes. Early on, it became evident that such a streamlined process was difficult to accomplish in practice. Based on the rural reality, the five case studies eventually dealt with somewhat different issues defined by the local contexts and associated interventions. Some had greater emphasis on planning, while others placed greater emphasis on aspects of recruitment and/or retention. Instead of perceiving this as a problem, we saw this as a stepping-stone for the development of a more real-life-fitted model.
Table
1 gives an overview of the case studies in each country. Specifically, the Swedish case study was focused on recruiting and retaining key personnel to the rural municipality of Storuman [
40]; the Norwegian case study aimed at improving the recruitment and stability of regular general practitioners in three rural municipalities [
41]; the Canadian case study focused on stabilizing the physician workforce in Nunavut, the most northerly territory of Canada [
42]; the Icelandic case study focused on recruiting and retaining specialized physicians in Akureyri Hospital, a rural teaching hospital in the northern part of Iceland [
43]; and the Scottish case study was aimed at improving the recruitment and retention of health and social care multi-disciplinary teams in remote and rural Scotland (Highland, Orkney, and Shetland) [
44].
Table 1
Case studies’ overview: aims and targeted strategic Framework elements
Case study aim | Recruit healthcare personnel to Storuman municipality | Improve recruitment and retention of GPs in three case municipalities | Stabilize the physician workforce in Nunavut | Recruit and retain specialized physicians in Akureyri Hospital | Improve recruitment and retention of rural multi-disciplinary teams |
Plan | Assess population service needs | | All municipalities evaluated their service model and ended up extending their number of GPs with one extra GP to reduce the workload. | | | Develop marketing strategies; friendly and informative RR communication processes and information packages; and identify appropriate and accessible education and support. |
Align the service model with population needs | Development of the contract model for new physicians. |
Develop a profile of target recruits | | Inuit/northern physicians serving Inuit. |
Recruit | Emphasize information sharing | Establishing an alumni register to send newsletters with job relevant information to people (approx. 2800) who might be interested in moving back to Storuman. | Development of a cultural orientation app for healthcare providers in Nunavut. | Information meetings with Icelandic medical students in Iceland, Hungary, and Slovakia, and with Icelandic specialists and specialists in training working in Sweden to introduce and promote the hospital. | Accessible user-friendly marketing outlets promoting rural vacancies. Development of an effective template including information on recruit profile, work area, work colleagues, and what rural and remote working in the area is like. |
Community engagement | Establishing a relocation coordination officer in Storuman municipality. | | Including a member from the community council in the project group. | Co-designing community information for candidates. |
Supporting spouses/families | Development of a couple recruitment strategy. | | Meeting with potential recruits and their families with a member from the municipality to inform of opportunities. | Develop and implement a buddy support system and educational support package. |
Retain | Supporting team cohesion | | | | Team approach to developing vacancy adverts. |
Ensure relevant professional development | Establishment of a programme with salaried educational positions for GPs to specialize in family medicine (ALIS-Vest/ALIS-Nord). | Continuing Education and Professional Development (CEPD) events for physicians. | Development of a tailored education programme for new recruits. Some physicians got 3 months extended educational leave to auscultate and do research work. | Piloting of ebook to aid access to evidence based practice. Development of new Multi-Professional Rural Practitioners Programme and Qualification Pathway. |
Training future professionals | Developing a rural education stream as part of the medical school curriculum at Umeå University. | | Health careers promotion camp for high school students from around Nunavut. | Work to get accreditation from the Royal College of Physicians to allow Akureyri Hospital to educate specialist in internal medicine and anaesthesia. | Multi-professional partnership package promoting joint training across professions. |
A project plan was developed for each case, and project activities were ongoing for 18 months. A case study report template was developed to ensure a common approach to reporting. It included a description of partners and purpose of the collaborative work, project activities and timeline, resources required, narrative descriptions of key outcomes, and lessons learned. All partners took an additional step for creating sustainability plans for the recruitment and retention initiatives addressed in their case study. A common template for this was also developed.
The concrete experiences from the case studies and the long-term perspective built in by the sustainability plans helped to clarify the strategic elements that were eventually incorporated into the Framework. The findings from the different case studies were integrated, although not all case studies provided input for every aspect of the Framework. A coordinated approach to the wording of the documents and design of the Framework was undertaken by a communication working group. The development and fine-tuning of the Framework progressed through an iterative process in four in-person workshops where the whole partnership met for several days for updates and discussions, and by virtual steering group meetings held on a regular basis throughout the project period.
Reflexivity
The Framework was developed through a protracted reflexive process in which the topic of recruitment and retention was investigated from many different starting points and approaches. The long duration of this collaborative work provided all partners with time to reflect on and validate the relevance of the different aspects of the Framework. Common elements of workforce recruitment and retention that are possible to address regardless of local context were identified even though each partner worked within different settings and health systems. Validation occurred through the process of testing concepts against the literature, including the previous Recruit and Retain project, and practical experiences in the five case studies. In addition to the four face-to-face workshops, the prototype Framework was presented also at conferences so that interested colleagues beyond the project partners contributed to the validation process.
Discussion
The
Framework for Remote Rural Workforce Stability identifies actions that can be taken by various levels of government and by local agencies. Local or regional agencies can use this
Framework to initiate dialogue with federal governments about their shared role in advancing rural and remote health services. The goal in any community or region would be to identify which elements of the
Framework are likely to have the greatest impact in their local reality, then design a set of interventions to implement them and move towards long-term workforce stability [
32].
The Framework can be implemented as a holistic, integrated set of interventions. However, it is not a recipe to be followed precisely or in any particular sequence, to achieve results. The available human resources and time might be limited in real-life settings. It was, therefore, important to develop a flexible tool from which it is possible to implement selected strategic elements among the total nine. Based on our case studies, we know that concentrating effort into one or a few of the nine strategic elements can give recruitment and/or retention improvements.
Our research and development project was limited in its ability to achieve the original goal of a consistent framework for implementation and evaluation across countries. Although rural and remote communities have much in common with each other across jurisdictional boundaries [
35], it was clear early in the project that each country participating in this research study was in a unique state. As a result, the
Framework, a robust, evidence-informed toolkit, was developed and is now ready for implementation and further validation in different countries around the world. There is substantial potential for further research and for practical experience in utilizing the
Framework. Further research into implementing the
Framework will need to be informed by changing expectations among health professionals who are potential recruits into remote rural health services [
46].
Our experience was that rural communities often have more in common with rural communities in other countries than they do with urban centres within their own national borders. Investing in training of people from rural and remote communities, in rural and remote locations, for rural and remote jobs, leads to more successful recruitment and stability of services in these locations [
3,
36]. However, every remote rural community is unique. Active community participation is essential to ensure the success of initiatives that target remote rural communities [
47,
48]. Top-down initiatives are doomed to fail.
As pointed to in the “Introduction” section, there is substantial literature describing individual interventions by different stakeholders that are more or less effective in recruiting and retaining healthcare personnel in rural and remote areas [
1,
2,
22,
32]. In contrast, the literature presents very few practical and actionable tools to undertaking this complex and multi-faceted task. Cosgrave [
49] points to the fact that most existing frameworks tend to be highly complex, including comprehensive lists of factors involved in recruitment and retention. While such models likely assist in building understanding around the complexity of the rural health workforce issue, they do not necessarily support the development of strategic, practical actions. The problem is now well understood, and the impacting factors clearly identified [
22,
50]. However, despite this strong evidence base, rural health services and their communities remain unclear about the actions they can or should take to improve their recruitment and retention situation. The utilization and further validation of the
Framework will be an indication of how suitable it is in tackling real-world recruitment and retention problems in remote and rural areas. We welcome additional research on recruitment, retention, and workforce stability outcomes from the use of the
Framework in different local contexts around the world.
There are already examples of implementing the
Framework in other settings. In January 2019, the
Framework was launched via a multisite video forum at which the five country case studies were presented, and each partner began the process of exploring the potential for implementing the
Framework in different settings. In Canada, the
Framework provided the basis for workshop discussions focused on the
Physician Resources Action Plan for Northern Ontario that had been developed following “Summit North: Building a Flourishing Physician Workforce in Northern Ontario” in January 2018 [
51]. Specifically, there was exploration of community engagement: whom to engage, what to discuss, and how to engage. Small group discussions then fleshed out: the conditions for success drawing on the partnership pentagram (policymakers, health service administrators, healthcare providers, academic institutions, and communities) [
52], leadership commitment, and monitoring and evaluation.
The Norwegian Ministry of Health and Care Services and the Colombian Ministry of Health and Social Protection have signed a Memorandum of Understanding on health cooperation called Rural Health for Peace. Among the issues to be developed are primary healthcare and health services in rural and remote areas. The Framework is being used as the basis for collaborating with local small communities, health agencies, and academic institutions to enhance the quality, effectiveness, and sustainability of healthcare in Tolima province. The Framework has been translated into Spanish and adapted to the Colombian context and is guiding specific research and development initiatives. Community engagement is a key feature of Rural Health for Peace, actively involving local communities including former FARC—Revolutionary Armed Forces of Colombia (People’s Army) combatants.
In Scotland, the
Framework has been included as a key element within a proposal to develop a
Centre of Excellence (CoE) for Remote, Rural and Island Healthcare aimed to improve and innovate health and care provision including the recruitment, retention, and support for health and care staff. The CoE proposal has been co-produced by a multi-agency and community working group led by NHS Education for Scotland and has been submitted to the Scottish Government in response to recommendations made within the Sir Lewis Ritchie Report [
53].
In Sweden, the Framework functions as a backbone for the local healthcare district of South Lapland-Region Västerbotten’s transformation of primary healthcare services, as one of four model areas in Sweden connected to the Swedish primary care reform. It is also used to structure a study through the Nordic Council of Ministers, which aim to give voices for how digital transformation of healthcare and social care services can influence recruitment and retention possibilities.
The preliminary work for Recruit and Retain: Making it Work focused on health services with an additional strategic focus on the broader public sector, and across the international collaborative. In the next phase, many partners extended their case studies beyond health services to education and other essential public services. In addition, engagement with the private sector operating in rural and remote environments including mining, retail, and regional economic development organizations confirmed that the rural private sector faces similar personnel recruitment and retention challenges and can benefit from applying this Framework.
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.