Designing medical internships to improve recruitment and retention of doctors in rural areas

Workplace locations of allied health and nursing graduates who undertook a placement in the Northern Territory of Australia from 2016 to 2019: An observational cohort study

OBJECTIVE

The aim of the study is to determine the current work locations of allied health professionals and nurses who undertook a student placement in the Northern Territory of Australia from 2016-2019.

DESIGN

An observational cohort study was conducted in October 2020, with students emailed a link to an on-line survey, plus two reminders.

SETTING

Primary health care in the Northern Territory of Australia.

PARTICIPANTS

All allied health and nursing students who undertook a student learning placement in the Northern Territory from 2016-2019 (n = 1936).

MAIN OUTCOME MEASURES

Practicing nurses and allied health professionals were asked about their work history and locations (coded using the Modified Monash Model of remoteness and population size).

RESULTS

The response rate was 14.2% (275/1936 students). Most respondents reported that their placement positively influenced them to consider working: in a rural or remote location (76%), in the Northern Territory (81%), and with marginalised or under-served populations (74%). Of the respondents, 224 had graduated and 203 were currently working in their health profession. A total of 31.4% of respondents reported that they had worked in a remote or rural location after graduation.

CONCLUSIONS

The student placement had a positive effect on the likelihood of students working in a rural or remote location. A focus on recruiting students with a remote upbringing/background and offering longer placements would likely be successful in helping build the health professional workforce in remote locations.

Interventions for health workforce retention in rural and remote areas: a systematic review

BACKGROUND

Attracting and retaining sufficient health workers to provide adequate services for residents of rural and remote areas has global significance. High income countries (HICs) face challenges in staffing rural areas, which are often perceived by health workers as less attractive workplaces. The objective of this review was to examine the quantifiable associations between interventions to retain health workers in rural and remote areas of HICs, and workforce retention.

METHODS

The review considers studies of rural or remote health workers in HICs where participants have experienced interventions, support measures or incentive programs intended to increase retention. Experimental, quasi-experimental and observational study designs including cohort, case-control, cross-sectional and case series studies published since 2010 were eligible for inclusion. The Joanna Briggs Institute methodology for reviews of risk and aetiology was used. Databases searched included MEDLINE (OVID), CINAHL (EBSCO), Embase, Web of Science and Informit.

RESULTS

Of 2649 identified articles, 34 were included, with a total of 58,188 participants. All study designs were observational, limiting certainty of findings. Evidence relating to the retention of non-medical health professionals was scant. There is growing evidence that preferential selection of students who grew up in a rural area is associated with increased rural retention. Undertaking substantial lengths of rural training during basic university training or during post-graduate training were each associated with higher rural retention, as was supporting existing rural health professionals to extend their skills or upgrade their qualifications. Regulatory interventions requiring return-of-service (ROS) in a rural area in exchange for visa waivers, access to professional licenses or provider numbers were associated with comparatively low rural retention, especially once the ROS period was complete. Rural retention was higher if ROS was in exchange for loan repayments.

CONCLUSION

Educational interventions such as preferential selection of rural students and distributed training in rural areas are associated with increased rural retention of health professionals. Strongly coercive interventions are associated with comparatively lower rural retention than interventions that involve less coercion. Policy makers seeking rural retention in the medium and longer term would be prudent to strengthen rural training pathways and limit the use of strongly coercive interventions.

Retention of physicians and surgeons in rural areas-what works?

BACKGROUND

Causes for health inequity among rural populations globally are multifactorial, and include poorer access to healthcare professionals. This study summarizes the recent literature identifying factors that influence rural doctor retention and analyses strategies implemented to increase retention. Uniquely, this study addresses the importance of context in the planning, implementation and success of these strategies, drawing on literature from high-, middle- and low-income countries.

METHODS

A systematic review of the English literature was conducted in two parts. The first identified factors contributing to rural doctor retention, yielding 28 studies (2015-2019). The second identified 19 studies up to 2019 that assessed the outcomes of implemented rural retention strategies.

RESULTS

Universal retention factors for health professionals in a rural environment include rural background, positive rural exposure in training or in the early postgraduate years and personal and professional support. Financial incentives were less influential on retention, but results were inconsistent between studies and differed between high-, middle- and low-income nations. Successful strategies included student selection from rural backgrounds into medical school and undergraduate education programs and early postgraduate training in a rural environment. Bundled or multifaceted interventions may be more effective than single factor interventions.

CONCLUSION

Rural health workforce retention strategies need to be multifaceted and context specific, and cannot be effective without considering the practitioner's social context and the influence of their family in their decision making. Adequate rural health facilities, living conditions, work-life balance and family, community and professional support systems will maximize the success of implemented strategies and ensure sustainability and continuity of healthcare workforce in rural environments.

Retention strategies and interventions for health workers in rural and remote areas: a systematic review protocol

OBJECTIVE

The objective of the current review is to examine the association between exposure to strategies or interventions to retain health workers in rural and remote areas of high-income countries and improved retention rates.

INTRODUCTION

Attracting and retaining sufficient healthcare staff to provide adequate services for residents of rural and remote areas is an international problem. High-income countries have specific challenges in staffing remote and rural areas; despite the majority of the population clustering in large cities, a significant number of communities are in rural, remote or frontier areas which may be perceived as less attractive locations in which to live and work.

INCLUSION CRITERIA

The review will consider studies that include health workers in high-income countries where participants have been exposed to interventions, support measures or incentive programs to increase retention or workforce length of employment or reduce turnover for health workers in rural and remote areas. Analytical observational studies, case-control studies, analytical cross-sectional studies, descriptive observational study designs, and descriptive cross-sectional studies published from 2010 will be eligible for inclusion.

METHODS

We will use the JBI methodology for reviews of risk and etiology. A range of databases will be searched. Two reviewers will screen, critically appraise eligible articles, and extract data from included studies. Data synthesis will be conducted, where feasible, with RevMan 5.3.5. A random effects model will be used to conduct meta-analyses. We will assess the certainty of the findings using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach.

Clinical specialty training in UK undergraduate medical schools: a retrospective observational study

OBJECTIVES

To determine if increased exposure to clinical specialties at medical school is associated with increased interest in pursuing that specialty as a career after foundation training.

DESIGN

A retrospective observational study.

SETTING

31 UK medical schools were asked how much time students spend in each of the clinical specialties. We excluded two schools that were solely Graduate Entry, and two schools were excluded for insufficient information.

MAIN OUTCOME MEASURES

Time spent on clinical placement from UK undergraduate medical schools, and the training destinations of graduates from each school. A general linear model was used to analyse the relationship between the number of weeks spent in a specialty at medical school and the percentage of graduates from that medical school entering each of the Core Training (CT1)/Specialty Training (ST1) specialties directly after Foundation Year 2 (FY2).

RESULTS

Students spend a median of 85 weeks in clinical training. This includes a median of 28 weeks on medical firms, 15 weeks in surgical firms, and 8 weeks in general practice (GP). In general, the number of training posts available in a specialty was proportionate to the number of weeks spent in medical school, with some notable exceptions including GP. Importantly, we found that the number of weeks spent in a specialty at medical school did not predict the percentage of graduates of that school training in that specialty at CT1/ST1 level (ß coefficient=0.061, p=0.228).

CONCLUSIONS

This study found that there was no correlation between the percentage of FY2 doctors appointed directly to a CT1/ST1 specialty and the length of time that they would have spent in those specialties at medical school. This suggests that curriculum adjustments focusing solely on length of time spent in a specialty in medical school would be unlikely to solve recruitment gaps in individual specialties.