Attraction and Retention

Canadian data shows that fewer physicians and nurses work in Canadian rural areas compared to urban settings. The choice to practice in a rural area is influenced by many factors: Coming from a rural background and having rural practice experiences during graduate training can promote uptake of rural practice. In contrast, poor perception of rural practice, especially in those not from a rural background, along with concerns over career opportunities and professional isolation can be deterrents to rural practice.

A lack of health-care providers can create gaps in services and limit health-care access for rural residents. Attracting sufficient health providers is necessary for the health and sustainability of rural communities.

Much is being done to enhance the pool of health providers in rural areas. Canada has a Rural Road Map with a set of strategies to bring more practitioners to rural Canada. The focus of the Road Map is for medical schools to enhance enrollment and training of students willing to practice in rural areas. There are nursing programs with a rural health focus, including Aurora College at Inuvik–NWT and the University of Northern British Columbia. There is also an effort to attract more non-physician health providers to rural Alberta to deliver health services. This includes nurse practitioners (NP), registered nurses (RN), physician assistants (PAs), and allied health providers.  

Rural communities play an important role in attracting and retaining health professionals. They make providers and their families feel welcome and help them settle into the new environment. Rural communities also create opportunities for local high school kids and health sciences students to get a taste of rural life and practice. This might help them consider rural practice. 

There are frameworks that help understand the factors that motivate health providers to choose rural practice. Communities can use these frameworks to tailor their attraction and retention strategies to individual needs. 

Together, all these strategies can boost access to health-care services in rural areas.  

Thoughtful short- and long-term strategies help to encourage health providers to practice in rural settings. Research has shown that there are different personal, professional, and community factors that influence a health professional’s willingness and desire to practise in a rural community. The reasons for staying in rural practice can be quite different from the ones that initially brought them there. 

Research on attraction and retention factors highlights three domains that require attention:  

1. Professional domain: factors that influence how well professionals integrate into an existing health care team and factors that affect their work-life balance and work satisfaction. 
2. Family domain: factors such as support for spouses and their families and how well they integrate into the community, fit of the health-care provider with the community, and personal characteristics. 
3. Community domain: community infrastructure (such as schools, recreational facilities, day care programs), health-care infrastructure, the socio-political environment (e.g., how vested the community is in the health and wellbeing of their residents), and the connections a community forges with the health professionals. 

This framework can help communities create a thorough plan and target all relevant domains.

Much time, effort, and funding has been invested to attract health professionals to live and practice in rural and remote Canada. Rural Health Professions Action Plan (RhPAP) has investigated successful strategies that rural Alberta communities use to attract and retain physicians and other health-care providers. Twelve rural Alberta communities participated in this study (i.e., six in the North Zone, four in the Central Zone, and two in the South Zone). They were selected based on their successful history of attraction and retention.  

The study used an established attraction and retention framework to organize strategies according to their focus on professional, family, and community domains. The study found that communities use a wide range of strategies in all three areas: 

Professional strategies:

• developing collaborative practice models and strategies to enhance work-life balance and mutual support (e.g., flexible on-call scheduling, mentoring) 
• creating opportunities for broad scope of practice, research, and continuing education 

Family strategies:  

• connecting newcomers to people and resources 
• offering housing support 
• connecting partners/spouses with jobs and volunteer opportunities 

Community strategies:  

• hosting community welcome tours for physicians and their partners/ spouses 
• showcasing community infrastructure 
• securing funding for new health-care equipment 
• organizing events to attract local talent and to recognize health-care providers 

Study participants (i.e., health-care providers, physicians, community members) ranked health-care infrastructure, professional integration, connections with the community, and partner/spouse integration as most important for attraction. Community infrastructure, work-life balance, work satisfaction and partner/spouse integration were ranked most important to keep the providers in the community.  

Many of the strategies are firmly established and have been successfully implemented over time. The study demonstrates that by using multiple strategies, communities have effective tools to attract and retain health-care providers and their families  in rural communities. 

The “pipeline to rural practice” is the education and training pathway created by medical schools to promote rural practice. Universities and other organizations, including RhPAP, use a mix of strategies to support a “pipeline to rural practice”.

Strategies include:

• recruiting students from rural backgrounds,
• offering financial support to rural students and residents,
• delivering training in partnership with rural communities,
• offering curriculum with repeated rural exposures, and
• building regionally based postgraduate training pathways.

Early outreach is important to show rural students that they can be successful in a medical career. The two Alberta’s medical schools use different strategies to recruit rural students into their undergraduate medical programs. The University of Calgary offers targeted scholarships to help students from lower socio-economic backgrounds throughout their undergraduate degree and into medical school. Indigenous and rural students are given preference for these scholarships. In contrast, the University of Alberta reserves some medical seats in each class for rural students to encourage rural applicants.

Medical and dentistry students can also access substantial bursaries through the Northern Alberta Development Council (NADC). Students must commit to one year of return service for each year of bursary support received.

At a recent event co-hosted by the University of Calgary and RhPAP, high school students across Alberta could learn about the rural medical education pathway and connect with current medical students from rural communities.

Once accepted into an undergraduate medical program, students can choose rural placements, connect with rural-based faculty members, and participate in rural interest groups. Both medical schools also offer longitudinal integrated clerkships, where medical students live in a rural Alberta community for 12 months gaining hands-on training.

After completing their undergraduate medical degrees, residents have the option to join a rural family medicine residency program. They can also deepen their skills in anesthesiology, emergency medicine, addiction medicine, or care of the elderly through nationally accredited programs. These skills are highly valued when practicing in rural communities.

RhPAP contributes its part to the rural pipeline by helping rural communities host skills days for high school students through the ‘Let’s Go Rural!’ program. Rural upbringing is one of the predictors for health professionals choosing rural practice. Introduction to health care careers may encourage these high school students to study to become a health care professional and return to their community to work.

Another predictor for rural practice is exposure to rural training and experience. RhPAP organizes skills-weekends for post-secondary health professional students in rural communities. Through these skills events, students can get a feel for what rural practice would look like, which may influence their eventual decision of where to work.

These events are not all about work though – there are lots of fun activities where students can meet the community and learn local about customs.

RhPAP also offers and organizes free accommodations for medical and health professions students that choose a clinical placement or training in rural communities. The accommodations come with everything a student needs – from small appliances to cleaning supplies and cooking utensils.

By organizing these accommodations, RhPAP not only removes financial and logistical barriers for students who want to explore rural practice but also helps create great experience for them.

RhPAP further supports the Rural Locum Services to cover absences of physicians.

The whole investment into rural strategies seems to be paying off. There is evidence in the national and international literature that physicians with rural education experiences more often end up working in rural communities. Closer to home, we have some success stories how a rural skills weekend convinced a recent graduate nurse that rural practice was the right thing for her.

Check out the stories of the four 2020 RhPAP medical student award recipients and what they have to say about rural practice:

• Kristi Mellom, third-year medical student – why doing her Rural Integrated Community Clerkship program in Camrose is such a rich experience
• Logan Sept, second-year medical student – what he loves about small town practice
• Sarah Walton, first-year medical student – why rural practice leads to more growth and confidence as a practitioner
• Zach Gorham, second-year medical student – how rural practice offers a broader perspective

When talking with Alberta rural residents, it is clear that they are passionate about rural living. They often highlight the beautiful surroundings and opportunities for outdoor activities. When considering rural practice, health providers look for more than a great place to work. They want to fit into the fabric of the community and its lifestyle, and feel comfortable raising their family. Showcasing all of a community’s assets is an important strategy when trying to woo health-care providers to take up local practice.

Many Alberta rural communities host welcome tours for potential physician candidates. These tours are carefully orchestrated to showcase all the community has to offer. Before the visit, community members gather information on the physician and their family. This helps them to better understand personal and recreational interests, family situation, faith orientation, and school requirements. This enables the community members to tailor the tour to the visitors’ interests.  

Community infrastructure is also important for retention, particularly from the view of health-care provider partners/ spouses. If they are missing important infrastructure like schools, after-school programs, day-care centers, it can be challenging to keep the family in the community. Some communities have gone through great efforts to establish day-care centres and/or build attractive multi-purpose facilities, in hope that they will be more attractive to new health care providers. 

One great example is Slave Lake, where the community raised funds for a new Community Centre that houses sports arenas, a day-care centre, performing arts venues, and a community hall. The vision was to build a year-round recreation facility with programs to inspire community residents to connect and strengthen their overall wellness. The centre is not only important for local residents, it is also a showcase facility to attract and retain new health-care providers to the area. 

What communities lack in infrastructure, they often make up through community events and programming. Communities include all sorts of activities on their welcoming tours such as snowmobile outings, rodeos, farm visits, oil field tours, and fishing. These activities highlight the best of rural life but also serve as a reality check of rural living. 

Many Alberta rural communities have a dedicated health-care provider attraction and retention (A&R) committee. These committees are instrumental in identifying and implementing strategies based on the needs and strengths of their communities.

The A&R committees are supported by RhPAP’s Rural Community Consultants, who help rural communities to get their A&R committees up and running. They also share successful strategies that other communities have used and train community members in leadership and community development skills. 

Partners and families play an important role in the decision of health professionals to take up rural practice. If partners or kids are not happy with their rural life, it is unlikely that the family will stay. Research shows the need to help partners/spouses integrate into the community in order to keep health care providers in the long term.

Once arrived, newcomers need continued support to settle into their new environment. Many communities help new hires and their families find housing. RhPAP also runs a housing program that can accommodate families in the short term. Communities often invite the new recruits and their families to community events and/or host dinner parties and BBQs for the newcomers to better connect them to other residents. 

Families with school-aged children integrate more easily into the community. Registering children in clubs or sports activities will expose them to other children and different activities. That way, the children quickly become part of the community: “If kids are well adjusted and make friends and are settled in, it’s harder to move because children are happy in the school”. It also helps the parents to get connected. 

 Integration is a lot easier if the partner/spouse works, because that is a natural way to make their own contacts in the community. – RhPAP 2018, ‘Building on Success’ project

Partners/spouses not finding a job is often cited as a reason for physicians leaving rural communities. Attraction & Retention Committees can help partners/spouses identify job opportunities. They often check in with partners/spouses before they move to the community to understand their needs and interests. This information helps to line up visits to local businesses and potentially negotiate job opportunities. Depending on the spouse’s profession, finding a job is not always easy, in particular if they are very educated. However, many success stories emerged where partners/spouses were matched with suitable jobs or started their own businesses with support of the community. 

 The spouse was an environmental engineer, so during the site visit, we set up a tour through the local mill, toured the facility and talked about different job opportunities to reassure the spouse that there are opportunities in the community. – RhPAP 2018, ‘Building on Success’ project

In recent years, communities have also focused on connecting and engaging with other health-care providers, not just physicians. This is important as all newcomers benefit from a little bit of help with settling in.  

Despite all these strategies, the community members and partners/spouses we spoke to said that the community could do more to help the families settle in. One Alberta community has gone the extra mile and hired a coordinator to look after the partners/spouses. They act as the go-to-person and help with anything from arranging childcare to finding the best place to shop. Most importantly, the coordinator keeps on checking in, even many months after arrival of the family. This ensures that families are supported in the long-term, increasing the chances that they will stay. 

To support rural workforce planning, it is helpful to be able to predict which medical and health sciences students will end up in rural practice. Research has found that coming from a rural background, having an interest in rural practice, and having rural training experience are the strongest predictors of future rural practice.  

 We could be more proactive in getting people thinking about coming back here in medical school; the community could give financial assistance in form of a bursary; it is a missed opportunity not doing that. – RhPAP 2018, ‘Building on Success’ project

The influence of rural background and rural training experiences for future choice to practice rurally has prompted a number of up-stream strategies. For example, some medical schools and health sciences programs have established programs with a northern focus that work closely with rural communities as education sites. Rural rotations and training opportunities are now embedded in most medical and health professions programs.  

‘Let’s Go Rural!’ is a program where RhPAP works closely with the rural Attraction and Retention (A&R) Committees to host experiences for post secondary students. The  A&R Committees partner with the local high school and universities, the medical community, and other essential services to arrange an interactive experience. During special events, students tour the health facilities and practice hands-on health care skills. They also hear from local health providers about their rural career and community experiences. These events include plenty of fun activities like BBQs, skeet shooting, and horseback riding to give the students a sense of the possibilities of rural living.  

Communities also focus on local students that are applying to medical school or are already in medical training. Physicians, with the help of the A&R Committee, connect with these future health care providers throughout the year.  

Physician returns to hometown to practice and farm

Physicians sometimes offer extra training through research projects, preceptorship opportunities, or education grants. Many of these programs are informal and based on a local physician’s enthusiasm and they would benefit from a more structured approach. 

Several communities run very successful medical residency and locum programs and those temporary physicians are now the main source of attraction of candidates for vacant positions. As one physician explained, she returned to the community because of the strong community connections that had been fostered and maintained during her training period; it was the strong mentors and great support that made her want to come back. 

Communities have found many ways to expose current and future medical and health sciences students to rural life and practice. Some of these strategies are paying off. There is a need to capture these success stories to find the most successful strategies to attract and retain future health professionals to rural practice.