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Recruitment and retention of occupational therapists and physiotherapists in rural regions: a meta-synthesis Roots, Robin K; Li, Linda C Feb 12, 2013

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RESEARCH ARTICLE Open AccessRecruitment and retention of occupationaltherapists and physiotherapists in rural regions:a meta-synthesisRobin K Roots1 and Linda C Li1,2*AbstractBackground: Significant efforts have been made to address the shortage of health professionals in ruralcommunities. In the face of increasing demand for rehabilitation services, strategies for recruiting and retainingoccupational therapists (OTs) and physiotherapists (PTs) have yielded limited success. This study aims to broadenthe understanding of factors associated with recruitment and retention of OTs and PTs in rural regions, through asynthesis of evidence from qualitative studies found in the literature.Methods: A systematic search of three databases was conducted for studies published between 1980 - 2009 specific tothe recruitment and retention of OTs and PTs to rural areas. Studies deemed eligible were appraised using the McMasterCritical Review Form. Employing an iterative process, we conducted a thematic analysis of studies and developedsecond order interpretations to gain new insight into factors that influence rural recruitment and retention.Results: Of the 615 articles retrieved, 12 qualitative studies met the eligibility criteria. Our synthesis revealed thattherapists’ decision to locate, stay or leave rural communities was influenced to a greater degree by the availability ofand access to practice supports, opportunities for professional growth and understanding the context of rural practice,than by location. The second-order analysis revealed the benefits of a strength-based inquiry in determining recruitmentand retention factors. The themes that emerged were 1) support from the organization influences retention, 2) withsupport, challenges can become rewards and assets, and 3) an understanding of the challenges associated with ruralpractice prior to arrival influences retention.Conclusions: This meta-synthesis illustrates how universally important practice supports are in the recruitment andretention of rehabilitation professionals in rural practice. While not unique to rural practice, the findings of this synthesisprovide employers and health service planners with information necessary to make evidence-informed decisionsregarding recruitment and retention to improve availability of health services for rural residents.Keywords: Recruitment, Retention, Workforce, Physical therapy, Occupational therapy, Continuing professionaldevelopmentBackgroundRural health care is gaining recognition as a distinctentity with unique challenges. In Canada, rural healthis characterized by a higher prevalence of chronic dis-eases and traumatic injuries [1] as compared withurban areas, as well as higher rates of overweight andobesity [2], lower life expectancy [1], and fewer healthcare resources including health professionals [1,3].While no single definition of rural exists, StatisticsCanada defines ‘rural and small town’ as regions thathave a population of less than 10,000 [2]. According tothe 2006 Census, approximately 20% of the Canadianpopulation live in these regions [4]. The relativelypoorer health profile in rural communities, combinedwith an aging population, suggest that there is a pro-portionally larger demand for services for medicaltreatment, rehabilitation, and health promotion.* Correspondence: lli@arthritisresearch.ca1Department of Physical Therapy, University of British Columbia, Vancouver,BC V6T 1Z3, Canada2Milan Ilich Arthritis Research Centre, 5591 No. 3 Road, Richmond, BC V6X2C7, Canada© 2013 Roots and Li; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the CreativeCommons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, andreproduction in any medium, provided the original work is properly cited.Roots and Li BMC Health Services Research 2013, 13:59http://www.biomedcentral.com/1472-6963/13/59Occupational therapists (OTs) and physiotherapists(PTs) are critical members of the health care team, pro-viding direct patient care, education, and advocacy inthe community. Despite the high demand for services[5], only 5.9% of the occupational therapy workforceand 7.7% of the physiotherapy workforce in Canadaworked in rural areas in 2010 [6,7]. Furthermore, thetrend of migration from urban to rural is steadily de-creasing since 1996 when it was from 9% for PTs and8% for OTs, to 2% for PTs and a reverse of 2% OTs mi-grating from rural to urban in 2001 [8]. The imbalancein the supply and demand for health care services inrural and remote regions results in inequitable accessto services [9].To address the disparity between the need for andsupply of health services, there has been a growth inresearch on recruitment and retention of health careworkers in rural and remote areas. Despite the wealthof studies in this field, the shortage of health care pro-fessionals from all disciplines in rural communitiesdoes not seem to have abated signalling the need for abetter understanding of the strategies necessary to im-prove the situation.Strategies, such as educational interventions [10], fi-nancial incentives, regulations, and practice supportinterventions [11], have been used to attract health pro-fessionals to work in rural and underserviced areas.However, the effectiveness of these measures has notbeen well established in the literature. A 2009 Cochranereview of these interventions by Grobler et al. concludedthe evidence to be very weak due in part to poor studydesigns [12]. The majority of studies fail to measure theeffectiveness of the strategies, resulting in frequentrepeats of similar programs with limited progress in thefield. In an analysis of the determinants of geographicalmaldistribution of the health workforce, Dussault andFranceschini noted that most of the strategies targetedshort-term factors, such as individual and social factors[13], and neglected to address broader factors, such asorganizational challenges, which have a much longerlasting effect. Wilson et al. reviewed rural workforce pol-icy in Australia and noted a focus on the shortage ofphysicians rather than the shortage of all health pro-fessionals across the health care system [14]. Lee andWinters also found that recruitment and retentionstrategies centred on medicine and nursing [15].Given the differences in the contextual environment inwhich professionals practice, recruitment and retentionstrategies from medicine and nursing may not be trans-ferable to rehabilitation professionals. For example, OTsand PTs often work in isolation [10], which may result indifferent individual, social and organizational needs.These differences further challenge health human re-source workforce planning and policy [14]. Hence, inorder to improve access to health care services for peopleliving in rural areas, we need to better understand keycontextual factors in recruiting and retaining health pro-viders to rural areas, in particular OTs and PTs [16,17].Factors specific to the rehabilitation workforceResearch on the determinants of individual factors asso-ciated with recruitment of rehabilitation professionalsto rural areas has identified a strong association withhaving a rural background [18,19], exposure to ruralpractice during training [18], and financial incentivessuch as loan forgiveness [19]. Personal characteristicsassociated with recruitment and retention to rural areasinclude desire to serve community needs [19] and per-ceived satisfaction with opportunities for professionalgrowth [10,20]. Social factors that are common to bothrecruitment and retention of OTs and PTs includeproximity to family [10], desire for a rural lifestyle[10,19], attractive job opportunities for spouse [10], andcareer and family ties [21].Studies on retention of OTs and PTs have centred onunderstanding factors associated with relocation to lar-ger centres. Individuals who leave their rural practicetended to be younger, male and single [20], lived faraway from their family, reported a lower spousal satisfac-tion with rural lifestyle, and reported poor job opportun-ities for self and spouse [21]. Organizational factors,such as management structure and lack of professionalsupport, were also associated with OT and PT attrition[21]. In a study by Beggs and Noh, PTs in NorthernOntario were more likely to remain in rural areas if theywere in private practice [20]. The authors suggested thatthis might be due to the autonomy afforded to privatepractitioners, seen as important to the provision of ser-vices in rural areas.While observational studies have provided ample fac-tors associated with recruitment and retention of healthprofessionals in rural areas, there has been limited suc-cess in mitigating the maldistribution of the healthhuman resource workforce. Dussault and Franceschiniconcluded that the multifaceted nature of recruitmentand retention requires a multifaceted strategy [13] andunderstanding of the context in which practitioners’practice. To our knowledge, there has not been a reviewof the qualitative literature on recruitment and retentionof rehabilitation professionals in rural areas to examinethe context, such that lessons learned may be integratedinto multifaceted strategies to increase the number ofOTs and PTs in rural areas.To broaden our understanding of why some factorsand determinants are important to recruitment and re-tention, and the influence that context has on the recruit-ment and retention of OTs and PTs to rural areas, weconducted a meta-synthesis of the qualitative literatureRoots and Li BMC Health Services Research 2013, 13:59 Page 2 of 13http://www.biomedcentral.com/1472-6963/13/59in this area. A meta-synthesis is designed to advance know-ledge through a summary of the qualitative research be-yond what is already known [22]. This methodology helpsto move policy forward through enlarging our understand-ing [23] and offering direction for future research.MethodsSearch strategy and article reviewA systematic literature search was conducted by one ofthe authors (RKR) using Medline (1980 to December2009), EmBase (1980 to December 2009) and CINAHL(1982 to December 2009). Search terms used included:‘rehabilitation’, ‘rehabilitation professionals’, ‘allied healthprofessions/ professionals / personnel / occupations’,‘physiotherap*’, ‘occupational therap*’, ‘rural’, ‘rural health’,‘rural service delivery’, ‘health care services’, ‘workforce’,‘recruitment’ and ‘retention’. In addition, we performedtwo hand searches. The first was of reference lists of allarticles selected as meeting our inclusion criteria. Thesecond hand search involved journals selected as rele-vant and pertinent to this area: Australian Journal ofRural Health and the International Electronic Journal ofRural and Remote Health Education, Research andPolicy published between 2005 and 2009.Articles were eligible for the review if they met the fol-lowing criteria: 1) included OT and PT research partici-pants; 2) reported on issues, factors, and/or strategiesrelated to recruitment and retention; 3) focused on ruraland/or remote areas; and 4) used qualitative methodolo-gies or analytical techniques. As no standardized defin-ition of rural exists internationally in the literature, weaccepted all definitions of rural. Articles were excludedif they did not use qualitative methodologies or analyt-ical techniques, or if they were not published in English.Results of the search were compiled and the first author(RKR) screened all titles and abstracts and reviewed thefull content of articles that met the inclusion criteria.Data synthesisWe followed the methodological framework for a meta-synthesis outlined by Gewurtz et al. [22]. While appraisalof the qualitative literature remains a controversial topicdue to its origins in the quantitative paradigm [24-28],we chose to assess the quality of all eligible articles toadvance understanding of the context of each study andthe variations in the qualitative literature. The level ofquality of articles was not a criterion of exclusion[29,30], however we hope that it serves to inform futureresearch. We used the Critical Review Guidelines forQualitative Studies developed by the McMaster Univer-sity Occupational Therapy Evidence-Based ResearchGroup [31] as it aligned most closely with the nature ofthe literature being reviewed. Each article was evaluatedfor quality based on eight criteria: 1) study purpose;2) literature; 3) study design; 4) sampling; 5) datacollection; 6) analyses; 7) rigour; and 8) conclusions /implications. The scale (Table 1) is detailed in its evalu-ation of the research quality and can be scored on apoint system (each section receiving a score of 1 = thecriterion was met; 0 = the criterion was not satisfied),with a maximum score of 18 [32,33].This meta-synthesis was conducted in accordance withthe methodologies outlined by Mays and Pope [26], andthe procedures used by Reid et al. [32] and Sandelowskiand Barroso [23]. Initially, all factors relating to recruit-ment and retention were extracted. Data synthesis wascompleted by the first author (RKR) and reviewed by thesecond author (LCL) to ensure congruency of themes.Thematic analysis [34] was chosen as the method ofanalysis as it allowed us to examine why certain fac-tors and determinants were important to recruitmentand retention of OTs and PTs to rural areas, as wellas to identify the influence of context on the recruit-ment and retention.Each eligible article was reviewed, the recruitment andretention factors were identified (Table 2), and the con-textual foundations of the research were extracted(Table 3). The findings were summarized and inductivelyanalysed for common and recurring themes [35]. Similar-ities and variations were juxtaposed and translated fromone study to another [26] and consideration was given asto how each theme related to each study. Through thisprocess, new explanations for why and how themes oc-curred were identified and re-evaluated in the context ofthe literature. This integrated methodology of inductiveand deductive thematic analysis resulted in second orderconceptual themes. Finally, we considered these conceptsfor policy and practice implications.ResultsSystematic searchThe systematic literature search retrieved 615 articles,12 of which met the eligibility criteria (Figure 1). Withthe exception of one study set in northern BritishColumbia [36], the research included in this synthesisoriginated from Australia where the issue of healthhuman resource shortages in rural areas is a focus ofmuch rural health research.While all studies reviewed in this synthesis includedOTs and PTs, there was significant variation in the sam-ple populations (Table 2). Five of the studies includedstudents or new graduates [37-41], and two studiesincluded therapists who no longer worked in rural or re-mote areas [39,42]. Across studies, there was noconsistency in the definitions of rural (Table 2). This fur-ther increases the complexity of comparing findingsacross the literature and applying conclusions to ruralpractice contexts.Roots and Li BMC Health Services Research 2013, 13:59 Page 3 of 13http://www.biomedcentral.com/1472-6963/13/59Table 1 Appraisal of the literature using critical review guidelines for qualitative studies developed by the McMaster University occupational therapyevidence-based research groupPurpose LiteraturereviewDesign Theory Method Sampling Saturation Consent DescriptiveclarityProceduralrigourBent 1999 Y Y Y Descriptive N Y Interviews N N N Y NButler & Sheppard 1999 Y Y Y Mixed methods comparative N Y Questionnaire Y Y Y Y YMills & Millsteed 2002 Y Y Y Ethnographic Y Y Interviews Y N Y Y YLee & MacKenzie 2003 Y Y Y Exploratory N Y Interviews Y N Y Y YDenman & Shaddock 2004 Y N Y Mixed methods N Y Focus groups, interviews & surveys N N N N NSteenbergen & MacKenzie 2004 Y Y Y Descriptive N Y Interviews Y N Y N NDevine 2006 Y Y Y Phenomenology Y Y Interviews Y Y Y Y YGillham et al 2007 Y Y Y Descriptive Y Y Interviews Y Y Y Y YThomas & Clarke 2007 Y Y Y Narrative inquiry Y Y Focus groups Y N Y Y NBoshoff & Hartshorne 2008 Y Y Y Descriptive N Y Questionnaire N N N Y NLe & Kilpatrick 2008 Y Y Y Exploratory N Y Interviews & written statement N N Y Y YManahan et al 2009 Y Y Y Descriptive Y Y Interviews Y Y Y Y YRootsandLiBMCHealthServicesResearch2013,13:59Page4of13http://www.biomedcentral.com/1472-6963/13/59Table 1 Appraisal of the literature using critical review guidelines for qualitative studies developed by the McMaster University occupational therapyevidence-based research group (Continued)Analytic rigour- inductive FindingsconsistentAudit trail Process of analysis ConceptualframeworkOverallrigourConclusion Contributionto theoryOverall score / 18Bent 1999 Y Y N Y Content analysis N N Y N 9Butler & Sheppard 1999 Y Y N Y conceptualization, cataloguing, linking Y Y Y Y 16Mills & Millsteed 2002 Y Y Y Y Content analysis Y Y Y Y 117Lee & MacKenzie 2003 Y Y Y Y Coding, comparative N Y Y N 14Denman & Shaddock 2004 N Y N N N N Y N 5Steenbergen & MacKenzie 2004 N Y N Y Codes & themes N N Y N 8Devine 2006 Y Y Y Y Thematic analysis N Y Y Y 17Gillham et al 2007 Y Y N Y Thematic analysis N Y Y Y 16Thomas & Clarke 2007 N Y N N Codes N N Y Y 11Boshoff & Hartshorne 2008 N Y N Y Descriptive statistics Content analysis Y N Y N 9Le & Kilpatrick 2008 Y Y N Y Thematic analysis Y Y Y N 13Manahan et al 2009 Y Y Y Y Thematic content analysis Y Y Y Y 18RootsandLiBMCHealthServicesResearch2013,13:59Page5of13http://www.biomedcentral.com/1472-6963/13/59Methodological appraisalEach study was evaluated for elements of high qualityqualitative research (Table 1) and to consider the impactthat the quality and rigour of each study had on theoverall findings. The majority of studies had a total scoregreater than 10 out of 18 and included the elements of aclearly stated purpose, appropriateness of design, meth-ods and sampling, consent and findings consistent withthe data collection. The weakest areas amongst the stud-ies synthesized were details of sampling procedures, useof theory, conceptual frameworks, contribution to theoryand overall rigour. The general absence of theory andconceptual frameworks makes transferability of resultsfrom these studies difficult [43].Of the studies reviewed, two indicated that they used adescriptive methodological approach, two employed anexploratory approach, one explicitly used an ethno-graphic methodological approach, one study applied aphenomenological approach, and one used a narrativeapproach. The remaining articles failed to indicate thequalitative methodological approach used and the major-ity did not ascribe to any theory to guide their research.Thematic analysis was used by five studies and contentanalysis was used by two studies. One study noted theTable 2 Characteristics of included studiesContext / Setting Definition of rural Sample Characteristics of rural practice / ruralpractitionersBent 1999 Central Australia Central Australia, NorthernTerritory considered to beremote17 OTs, PTs, SLP; excludedprivate practice, managementor consultantsLarge clinical caseloads, large geographicalarea, variety of age groups and conditionsButler & Sheppard1999Australia Rural defined as < 25000 58 PTs graduated within 2 years;(18 in rural and 40 in metropolitanareas)More likely to be sole charge, lessprofessional support, greater role aseducatorMills & Millsteed 2002 Australia Broad definitions citedand used10 OTs previously in rural practice;purposive sample and snowballBreadth and depth of professionalknowledge gained useful in all areas/settings of practiceLee & MacKenzie 2003 New South Wales,AustraliaClassification based ondensity and distance5 OT new graduates, (4 in publicpractice and 1 in private)Varied caseload, limited resources, limitedsupport, greater interactions with clientsand integration into community,professionals require independence &self-confidenceDenman & Shaddock2004New South Wales,AustraliaWork location > 1 hourdrive from a metropolitanregion (<250,000)Focus group of 1 OT, 2,PT, 2 SLP;31, surveys returned from 9 OTs,7 PTs, 13 SLP. Interviews with1 SLP, 2 mangers working indepartments providing disabilitiesservicesNone givenSteenbergen &MacKenzie 2004New South Wales,AustraliaParticipants decided 9 OTs in 1st year practice in rural;(7 public and 2 private sector)None givenDevine 2006 Australia Australian accessibilityremote index6 OTs newly graduated; 4 OTinstructorsGreater need for management skills,prioritization, time managementGillham et al 2007 Victoria, Australia Classification based ondensity and distance8 allied health profession students,7 managers, 18 allied healthprofessionals and 10 former staff;all public sectorNone givenThomas & Clarke 2007 Northern Territory,AustraliaNone given 18 AHP including OTs and PTs Skills and attributes for rural practice:being organized, creative, flexible,cooperative and collaborative, culturalawareness, communication, resourceful,reflective learner, networking, dual rolesand responsibilityBoshoff & Hartshorne2008South Australia,AustraliaCombined use of termscountry and rural, nodefinitions18 OT managers completedQuestionnaire; majority publicsectorMulti-skilling of therapists, problem solving,Le & Kilpatrick 2008 Australia None given 6 overseas born Australian trainedhealth care professionals including1 PTNone givenManahan et al 2009 British Columbia,CanadaBroad definitions citedand used6 AHP including: 6 SLP, 4 OTs, 4 PTs;no indication whether public orprivate sectorVariety, change, dual relationships,challenges, need for creativityRoots and Li BMC Health Services Research 2013, 13:59 Page 6 of 13http://www.biomedcentral.com/1472-6963/13/59Table 3 Meta-synthesis of recruitment and retention factorsRecruit factors Retention factors Recruitment and retention strategiesBent 1999 Working with aboriginal populations,team environment, permanent position,diversity of work, bush travel Deterrents:insufficient staff, management andorganizational problems, professionalisolation, vacant positions results inincreased workAccess to professional development,understanding of rural practice skillsby management and support frommanagement, cost of living,networking and communicationwith peersCross-cultural training / education,professional networking, managementsupport, information technology,heightened profile of rural practice-focus on the positives of living/ workingin rural, acknowledgement of ruralpractice as a specialtyButler & Sheppard1999Rural childhood and final placement inrural (regardless of mandatory) Studentsfelt prepared to take up positions in ruralareas Rural training module did increaseinterest in working in a rural area andawareness of life in rural communityRetention factors not identified Priorbackground in rural inconclusiveSimilar levels of support noted forrural and metro graduatesSupport and professional developmentcritical for new graduates regardless ofgeographical locationMills & Millsteed 2002 Appeal of the opportunity, variety of tasksDeterrents: lack of orientation to positionand to community, lack of support,isolation, high workloadPersonal factors- social sphere,compensation Professional factors-rural practice issues, rural experienceRetention is the balance betweenincentive to stay and incentives toleaveOrientation and assistance with buildingcontactsLee & MacKenzie 2003 Rural lifestyle, rural background, clinicalopportunity Deterrents: perceived lackof supportRural placement reinforces intentionsto stay in rural community;professional support valuedRecruitment from rural background andrural fieldwork experience. Peer support,feedback and evaluation, social contactand support networksDenman & Shaddock2004Lifestyle and personal factors, evidence ofsupport for professional development,‘critical mass’ of staff, professionalsupervision, career structureReasons to leave: partner movesaway, resource limitations,insufficient support, opportunityfor professional development,vacancies, work not valued bymanagementFlexibility by management (accommodationfor concerns relating to why people leaveor stay), creation of cross-sectorial teams,remuneration and employment conditionsindividualizedSteenbergen &MacKenzie 2004Professional support to build professionalidentityWide variety of resources requiredReasons to leave depleted resourcesand decreased educationNew graduates require support andprofessional development to establishprofessional identity regardless ofgeographical locationDevine 2006 Rural background (self or spouse), attractedto position not location, multidisciplinaryteam, personal autonomy, developmentof skill Undergraduate program focusedon problem solving skills and ability towork autonomouslyProfessional support includingeducational preparation anddevelopment Clinical placementin rural setting did not adequatelyprepare for rural practicePreparation by undergraduate course(including subjects such as health promotionand primary health care, autonomy)Development of skills and support forcompetency throughout careerGillham et al 2007 Rural background, rural placement or ruralconnection, career opportunities (rotatingpositions for new graduates), financialincentives, career progression, mentoring,access to professional support, supervision,social networks (especially for students)Career/ professional development,social network opportunities,management style & organizationalpolicy (collaboration between staff& management, consultation &open communication), flexibility inwork schedule, financial remunerationfor accommodation & relocationMentors, adequate human resources inorder to best practice, career opportunitiesThomas & Clarke 2007 Knowledge of community, role of healthcare professional in communityRelationships with other professionalsand community; time management,responsibility in the community,personal resourcefulness, adventureReasons to leave: stress, responsibilityDevelopment of skills and attributes intraining programsBoshoff & Hartshorne2008Variety of caseload and services delivered Reasons to leave: limited resources,high client to therapist ratio, lack ofprofessional support, strategies andcollaborationService delivery model specific to thesetting, networking and collaboration toreduce isolation, workplace support,account for recruitment factors andprofile of practiceLe & Kilpatrick 2008 Autonomy, the family oriented nature ofrural communitiesReasons to leave: cultural shock, lackof social and emotional support,communication and lack of collegialityProfessional development, assistance inaccommodating cultural needs anddecreasing distance through connectionswith colleaguesRoots and Li BMC Health Services Research 2013, 13:59 Page 7 of 13http://www.biomedcentral.com/1472-6963/13/59use of conceptualization and another conducted coding,but did not describe the process or categorization. Threestudies did not provide details of the analytic process.All studies conducted interviews and/or focus groups,and some added a questionnaire or survey. Only two ofthe 12 studies described triangulation of data, both ofwhich used a mixed methods design [37,44]. Memberchecking and use of an external auditor were used to en-sure research rigour in two of the 12 studies [36,40].First order analysis - themesOur first order analysis found organizational support[39,41,42,44,45] and opportunities for professional devel-opment [41,46] to be important factors in attracting andretaining OTs and PTs in rural areas. On first glance,these factors did not appear to be unique to rural prac-tice as they are universally valued by health professionalsregardless of geographical location. However, whenorganizational support and professional developmentwere viewed in light of the rural context and the chal-lenges associated with accessing professional develop-ment when practising in a rural area, these factorsappeared to have a stronger influence on recruitmentand retention than the common factors of geographicallocation relative to family and personal choices [45,46].Three themes emerged in the first order analysis: 1) theavailability of professional support was important toattracting and retaining PTs and OTs in rural areas; 2)the importance of opportunities for professional growth;and 3) the nature of rural practice.Theme 1: the availability of professional support wasimportant to recruitment and retentionProfessional support was cited by all 12 studies as import-ant to OTs and PTs working in rural areas. Our analysisidentified the availability of professional support for re-habilitation professionals in rural areas as a key factor forrecruitment and retention. Professional support included:1) an understanding of the characteristics of rural rehabili-tation practice by managers, the profession and other teammembers, and 2) having adequate resources to fulfill therequirements of the position/practice and access to con-tinuing professional development.In the analysis, we noticed that OT and PTs’ percep-tion of the extent to which support was available variedenormously. Some therapists felt supported by manage-ment [39,47] and by colleagues in other professions [39],whereas others perceived a general lack of support bymanagement and by urban practitioners in their ownprofession [40,42,45]. Receiving adequate professionalsupport was considered dependent on the managerialstyle and/or the overarching organizational policy[39,44,45,47,48]. OTs and PTs described feeling supportedwhen management offered them flexibility in their workschedule to accommodate distance travelled [39], or recog-nized the increased workload that occurred due to theshortage of rehabilitation staff [45]. Perceived lack of pro-fessional support appeared to result in poor retention [45],or the reluctance to accept or stay in a position [38,40].Professional support was cited as particularly im-portant for new graduates in rural areas to assist themFigure 1 Literature search results.Table 3 Meta-synthesis of recruitment and retention factors (Continued)Manahan et al 2009 Rural background, availability andaccessibility of training programs in ruralareas determined career choice, decisionto work in rural prior to work, need forhealth care professionals in ruralcommunity, positive past experience inrural communityAge and stage of life, proximity tofamily, career advancementopportunities, peer support,affordability, lifestyle, congruentwith life valuesAccount for age and stage of life, valuesin addressing personal and professionalfactors, admissions selection criteria oftraining programsRoots and Li BMC Health Services Research 2013, 13:59 Page 8 of 13http://www.biomedcentral.com/1472-6963/13/59to develop their professional identity [40] and transi-tion from student to professional [37-39,44]. In urbanand suburban centres, this could be achieved throughcontact with and mentoring of peers [37,40]. How-ever, because OTs and PTs in rural settings oftenwork in isolation, access to this type of informal pro-fessional support was limited and posed a barrier torecruitment [38,42]. In a comparative study, Butlerand Sheppard noted that rural therapists were lesslikely to have access to professional support thanmetropolitan therapists [37]. Half of the participantsin a study by Manahan et al. noted the importanceof peer support in their decision to stay in ruralpractice [36].Transcending the challenge of obtaining professionaldevelopment in rural areas required networking, collab-orating, problem-solving, shadowing, and mentoringother health care professionals [36,38,42,44,47,49] andmanagement [39]. Working closely with colleagues pro-vided support to OTs and PTs unfamiliar with proce-dures, and an opportunity to communicate regularly andbuild trusted relationships [44,49]. Denham et al. notedthat participants felt having a critical mass of staff wasessential for reducing the sense of isolation [44]. Inter-estingly, some therapists perceived managers from a dif-ferent discipline as lacking the understanding of thetypes of services offered by rehabilitation professionals[45]. This appeared to lead to a sense of decreased pro-fessional support [45].Our analysis also suggested that limited resources inrural areas were a challenge to practice [38,44]. Whilesome studies did not distinguish between humanresources and physical resources [40], the setting inwhich participants worked also appeared to be import-ant. More participants who worked in the public sec-tor identified having limited resources [40,44] or notbeing adequately resourced [41,42,45] than did partici-pants in private practice [41]. Gillham and Ristevskisuggested that the flexibility and autonomy of privatepractice might have contributed to a perception ofgreater control over the issues around resources [39].It should be noted that two studies [42,45] excludedparticipants if they worked in private practice. Withthe exception of a study by Boshoff et al. that sur-veyed front-line OTs and PTs as well as managers[47], therapists in a managerial role did not perceivethe additional need for support that resulted from geo-graphical or professional isolation.In summary, while professional support was found tobe a key factor for rural recruitment and retention, itwas apparent through the analysis that this supportneeded to come from management and/or organizationsthat understood rural practice, and from managers of arehabilitation discipline.Theme 2: importance of opportunity for professionalgrowthAccess to and availability of professional developmentwere listed as the greatest challenges to practising in arural area [36,38,39,41,45,47]. Having ‘room to growprofessionally’ [42] and ‘opportunity to grow’ withintheir career [36] appeared to be a central factor [39] inthe recruitment and retention of rehabilitation profes-sionals in rural areas.In the studies reviewed, OTs and PTs recognized thatthe challenges of rural practice, such as the diversity ofthe caseload, offered the opportunity to build their skillsin a number of different areas [47], and to be ‘expert gen-eralists’ in rural practice [45]. The breadth of rural prac-tice was noted by some participants [38,39] as a goodstarting point for their career as it allowed them to con-sider what areas they would later specialize in [42].Nevertheless, participants in a study by Butler andSheppard felt they needed more experience before takingon a rural position [37]. Regardless, rural employmentoffered greater responsibility and personal autonomy [38].Participants in a number of studies noted that insuffi-cient room to grow professionally or a flat career structure,combined with limited professional development oppor-tunities, contributed to decreased job satisfaction [45] andworkforce attrition [38,39,44]. Lee and McKenzie alsofound fear of deskilling to be a reason for practitioners’ re-luctance to go to or stay in a rural area [40].Theme 3: understanding the nature of rural practiceAn understanding of the nature of rural practice playeda vital role in recruiting and retaining rehabilitation pro-fessionals. Across studies, rehabilitation practice in ruralareas was described as occurring in a variety of work-place settings with a diverse caseload [45], a high clientto therapist ratio [47], and the necessity of therapists tohave a wide set of clinical and professional skills [38,47].As compared with OTs and PTs working in urban areas,therapists in rural areas were found to have a larger rolein providing education, greater one-on-one time withclients [37], and a greater proportion of work time trav-elling [47]. Devine et al. noted that it was the profes-sional opportunities associated with rural practice thatattracted therapists to the position rather than the geo-graphical location [38]. For example, in a study by Bent,the opportunity to work with aboriginal populations wasidentified as a feature of rural practice that brought re-habilitation professionals to rural areas [45]. Knowingand understanding these features of practice appears tohave an impact on recruitment and retention. Butler andSheppard suggested that clinical placements in ruralareas did not increase rural recruitment; however, place-ments contributed to retention due to more informeddecision making regarding location of practice [37].Roots and Li BMC Health Services Research 2013, 13:59 Page 9 of 13http://www.biomedcentral.com/1472-6963/13/59A number of studies in this review suggest that OTsand PTs who participated in these studies felt that theircolleagues, other health care professionals or organiza-tions did not understand the nature of rural practice, orrecognize the distinct features of rural practice[38,39,42,45]. It is generally accepted that this lack ofunderstanding and recognition contributes to poor recruit-ment and retention. Our first order analysis highlightedthe importance of professional support, opportunity forprofessional development and understanding the featuresand context of rural practice. This resulted in deeper ana-lysis to produce second order themes and the developmentof new interpretations of features of recruitment and reten-tion of OTs and PTs in rural areas.Second order analysisThrough deeper analysis of each theme in the first order,we gained additional insight into factors that contributeto the recruitment and retention of OTs and PTs to ruralareas. When we unpacked the first theme (availability ofprofessional support) for greater understanding, it be-came evident that professional support from theorganization was critical to retention. Embedded in thesecond theme of professional growth was the transform-ation of practice challenges into rewards and assets,which also contributed to retention rather than recruit-ment. Finally, analysis on the importance of understand-ing rural practice illustrated that understanding prior topractising in a rural area was a key factor for recruitmentand retention of OTs and PTs to rural practice.Professional support from the organization influencedretentionProfessional support was cited as important to OTsand PTs working in rural areas irrespective of thestage of career. However, when we examined the factorof professional support more closely, we noted that itsinfluence on recruitment or retention could be deli-neated along stages of career. Five studies [37-41]included new graduates in their sample and associatedavailability of professional support with recruitment torural practice. In a comparison of new graduates in ruralareas to those in urban areas, Butler and Sheppard foundnegligible difference in participants’ perception of sup-port for practice [37]. This suggests that new graduatesseek support to develop a professional identity and ob-tain a comfort level with their professional skills regard-less of practice location.Lack of professional support by the organization wascited commonly as a reason for leaving rural practice.Thus, it would appear that promises of support such ascontinuing education, adequate orientation and managerialsupport, which acted as attractants to rural practice, didnot materialize in the rural settings and contributed toattrition. The perception by OTs and PTs of professionalsupport being provided by the organization was a signifi-cant factor in retention of rehabilitation professionals torural areas.With support, challenges can become rewards and assetsSeveral studies employed an appreciative approach intheir research design, which reflected the positive per-spective by which some OTs and PTs viewed the isola-tion and resource scarcity of rural practice, and shed apositive light on the challenges presented in rural prac-tice [40,42,45]. Furthermore, appreciation shown by acommunity for rehabilitation services contributed to jobsatisfaction and retention [40].Initial analysis led to confusion as to whether a par-ticular factor contributed to recruitment or retention.Factors that attracted therapists to rural practiceappeared to be the same as those that deterred therapistsfrom entering or remaining in rural practice [42,49]. Forexample, the rural setting may have initially been an at-tractant but geographical isolation may also contributeto attrition [42]. It appeared that some OTs and PTssought the challenge of rural practice but also left be-cause of the challenge. When asked what the challengesand rewards were, participants noted autonomy [38,49],diversity of practice [45,47], relationships [46], and theneed for broader skills [38]. However, it was not clearwhether the challenges faced by OTs and PTs wereattributed to the position that they were in or to beingin a rural location [40]. Studies using a strength-basedline of inquiry in research framed these features as posi-tive factors to recruitment and retention necessitating acloser look at research study design.Converting the challenges of rural practice intorewards through positive experiences appeared to beassociated with retention. For example, if a therapistchose rural practice based on a desire for autonomy orworking with an aboriginal clientele and they receivedthe support necessary to remain in that role, this chal-lenge would be considered a positive reason to stay inrural practice [45]. Conversely, if a therapist was not pre-pared for the autonomy of rural practice, or did not receiveadequate support by management to maintain or build theknowledge needed for providing culturally appropriate ser-vices, the challenge resulted in attrition [45].When observing the results of the second theme, theimportance of opportunities to ‘to grow’ professionallywas linked with job satisfaction and was a significantpredictor of retention. Through interviews with thera-pists who left rural practice, Mills and Millsteed foundthat those who had the opportunity for advancementwhile in rural practice stayed the longest [42]. The op-portunity for advancement was a consistent factor in re-tention across all stages of career [36,39,41,42].Roots and Li BMC Health Services Research 2013, 13:59 Page 10 of 13http://www.biomedcentral.com/1472-6963/13/59An understanding of the nature of rural practice prior toarrival influences retentionIn examining the third theme, it became clear that priorunderstanding of the nature of rural practice had a sig-nificant effect on decisions to leave or to stay in rural.Whether obtained through lived experience or throughclinical education fieldwork placements, an understand-ing of the nature of practice in a rural setting prior toobtaining the position appeared to affect retention. Afew studies [36,40,49] identified that OTs and PTs whohad made the decision to pursue rural practice prior tobeing offered a position recognized the rewards in ruralsettings more so than the challenges.The mixed messages in the literature regarding therole of clinical education in influencing students andgraduates to work in rural areas [37,38] suggest thattraining programs do not consistently assist students inunderstanding the nature of rural practice. Boshoff andHartshorne found that the majority of recently gradu-ated OTs did not feel adequately prepared for rural prac-tice [47], but it was not clear whether these students hadparticipated in rural placements or were familiar withrural practice prior to working in a rural area. In con-trast, in 1999 Butler and Sheppard found that newlygraduated PTs were equally well prepared or better pre-pared in rural practice as compared to metropolitanpractice [37].Finally, while the analysis showed that prior understand-ing of the nature of rural practice was critical to retention,it remained unclear whether clinical education in ruralareas had a direct effect on recruitment or retention.DiscussionFindings from this meta-synthesis suggest that profes-sional support from management and organizations iscritical in the decision making of OTs and PTs to workin rural practice. Support was demonstrated throughrecognition and understanding of the features of ruralpractice, such as larger caseloads [40,45,50], limited re-ferral options [50], decreased access to resources[37,40,46,50] and limited access to continuing education[37,39,45,50], and through providing opportunities togrow professionally and convert these challenges intoopportunities for a rewarding career.On close examination of these first order themes dur-ing the second order analysis, we found that professionalsupport and prior understanding of rural practice had agreater influence on retention than recruitment. Our sec-ond order analysis also found that the line of inquiry of astudy has the potential to influence whether the factorhas a positive or negative influence on recruitment or re-tention. Where a strength-based approach was applied,challenges were framed as opportunities or rewards,while the majority of research questions focused onchallenges. Consideration should be given to the ap-proach taken when using research to inform the develop-ment of recruitment and retention strategies.The Model of Retention Equilibrium proposed byMills and Millsteed [42] weighs incentives to stay inrural practice against incentives to leave. It proves to bea useful framework in considering the interplay of fac-tors that influence therapists’ decision regarding locationof practice. This model could assist communities orhealth service organizations to weigh incentives to stayagainst incentives to leave and ‘tip the balance in favourof retention’ [42], and it offers a useful means to inter-pret the findings from the second order analysis.Through providing professional support, professional de-velopment and a greater understanding of rural practice,challenges of rural practice (that might be reasons to leave)can be turned into rewards and the incentive to stay.Despite controversial viewpoints on appraising thequality of qualitative studies, performing an assessmentof the studies reviewed in this meta-synthesis offered anadditional perspective on the studies’ context and on thevariation in quality of the research. In order for qualita-tive literature to contribute to progressing an issue bychanging policy or practice, it is necessary to situate theissue or phenomena within its local context, and link itto the broader literature and phenomena [24]. Overall,the studies reviewed in this meta-synthesis did notclearly define the context in which the research studytook place. Without a universal definition for rural[51,52] and given the heterogeneity of rural [53], it iscrucial that researchers clearly define the rural contextand the nature of rural practice they are researching.Furthermore, as recruitment and retention applies to allstages of careers and sectors of health care (public andprivate), there is a need to clearly delineate the partici-pant populations so research findings can better informhuman resource planning strategies.The majority of the studies reviewed did not relatetheir findings to a theory, framework or model, nor didany evaluate the effectiveness of recruitment and reten-tion strategies. Our analysis also found that most strat-egies were adopted as ‘bundles’ [54] rather than singlestrategies, which made evaluation difficult. A critical re-view of the recruitment and retention literature by theWorld Health Organization suggests that research makebetter use of theory and frameworks in order to addressthe multifaceted nature of recruitment and retention fac-tors and to better monitor and evaluate retention inter-ventions [55]. Models such as those presented byManahan et al. regarding the personal values and experi-ences of rural health professionals [36] and the Model ofRetention Equilibrium [42] provide a framework for situ-ating the complexity of factors and considering the ef-fectiveness of strategies in future studies.Roots and Li BMC Health Services Research 2013, 13:59 Page 11 of 13http://www.biomedcentral.com/1472-6963/13/59LimitationsIn search of greater insight into factors that influence re-cruitment and retention of OTs and PTs, this meta-synthesis chose to examine only qualitative literature, asmall subset of the recruitment and retention literature.As is the nature of qualitative research, results cannot beeasily generalized. However, after establishing the factorscommon to all studies in this review, this meta-synthesisestablished first order and second order themes thatprovide greater understanding of how personal and pro-fessional factors contribute to recruitment and retentionin rural contexts. While third order analysis has beendone in some meta-syntheses, we chose to stop at thesecond order as there was insufficient depth to the arti-cles we reviewed to achieve further conclusions thatwould contribute to or progress the literature.ConclusionsThe current health care environment places considerableemphasis on evidence-informed decisions, and healthhuman resource planning is no exception. This meta-synthesis offers an additional perspective on some of thefactors associated with the recruitment and retention ofOTs and PTs to rural areas. Of all the factors identifiedin the original articles and further analysed, professionalsupport from organizations was identified as having asignificant effect on recruitment of new graduates andretention across all stages of a career. Opportunities forcareer development and an understanding of the ruralcontext prior to practising in a rural area were recog-nized as significant factors in retention. These factorsshould be prioritized to inform strategies for healthhuman resource planning at all levels of academic andhealth organizations.This meta-synthesis also recognizes the need for re-search to clearly describe the context of rural practiceand consider how the positionality of the study (such asa strengths-based inquiry) influences the results. Wealso recommend the use of a theoretical framework ormodel to situate recruitment and retention factors in thecontext of what is known and evaluate the effectivenessof the strategies implemented.Finding effective and sustainable solutions to theissues of recruitment and retention of rehabilitation pro-fessionals to rural and remote areas will ultimately con-tribute to improving the care and health status of peopleliving in rural communities. To this end, we encourageacademic, professional and health care administrationcommunities to invest in professional and organizationalsupport as a part of their recruitment and retentionstrategy for rehabilitation professionals.Competing interestsThe authors declare that they do not have any competing interests.Authors’ contributionsRKR was responsible for carrying out the systematic literature review,analysis, interpretations and for drafted the manuscript. LCL was involved inreviewing the analysis, providing feedback and editing the manuscript. Bothauthors read and approved the final manuscript.AcknowledgementsThe authors wish to thank the Canadian Arthritis Network for their generousfunding of RKR as a research trainee and the Arthritis Research Centre foruse of office space.LCL is supported by the Harold Robinson/Arthritis Society Chair in ArthriticDiseases, a Canadian Institutes of Health Research (CIHR) New InvestigatorAward, and an American College of Rheumatology Research & EducationFoundation Health Professional New Investigator Award.Received: 6 July 2012 Accepted: 10 February 2013Published: 12 February 2013References1. Canadian Institute for Health Information: How healthy are rural Canadians?An assessment of their health status and health determinants. In Canada'sRural Communities: Understanding Rural Health and Its Determinants. Ottawa, ON:Canadian Institute for Health Information; 2006.2. Mitura V, Bollman R: The health of rural Canadians: a rural- urban comparison ofhealth indicators. 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BMC Health Services Research 2013 13:59.Submit your next manuscript to BioMed Centraland take full advantage of: • Convenient online submission• Thorough peer review• No space constraints or color figure charges• Immediate publication on acceptance• Inclusion in PubMed, CAS, Scopus and Google Scholar• Research which is freely available for redistributionSubmit your manuscript at www.biomedcentral.com/submitRoots and Li BMC Health Services Research 2013, 13:59 Page 13 of 13http://www.biomedcentral.com/1472-6963/13/59


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