"Who Works In Northern B.C.?" Identifying Personal Characteristics And Experiences Shared By Long-Term Health Professionals In Northern British Columbia Candice Manahan B.Sc, University of Northern British Columbia, 2001 Thesis Submitted In Partial Fulfillment Of The Requirements For The Degree Of Master Of Science In Community Health Science University of Northern British Columbia August 2008 © Candice Manahan, 2008 1*1 Library and Archives Canada Bibliotheque et Archives Canada Published Heritage Branch Direction du Patrimoine de I'edition 395 Wellington Street Ottawa ON K1A0N4 Canada 395, rue Wellington Ottawa ON K1A0N4 Canada Your file Votre reference ISBN: 978-0-494-48771-6 Our file Notre reference ISBN: 978-0-494-48771-6 NOTICE: The author has granted a nonexclusive license allowing Library and Archives Canada to reproduce, publish, archive, preserve, conserve, communicate to the public by telecommunication or on the Internet, loan, distribute and sell theses worldwide, for commercial or noncommercial purposes, in microform, paper, electronic and/or any other formats. AVIS: L'auteur a accorde une licence non exclusive permettant a la Bibliotheque et Archives Canada de reproduire, publier, archiver, sauvegarder, conserver, transmettre au public par telecommunication ou par Plntemet, prefer, distribuer et vendre des theses partout dans le monde, a des fins commerciales ou autres, sur support microforme, papier, electronique et/ou autres formats. The author retains copyright ownership and moral rights in this thesis. Neither the thesis nor substantial extracts from it may be printed or otherwise reproduced without the author's permission. L'auteur conserve la propriete du droit d'auteur et des droits moraux qui protege cette these. Ni la these ni des extraits substantiels de celle-ci ne doivent etre imprimes ou autrement reproduits sans son autorisation. In compliance with the Canadian Privacy Act some supporting forms may have been removed from this thesis. Conformement a la loi canadienne sur la protection de la vie privee, quelques formulaires secondaires ont ete enleves de cette these. While these forms may be included in the document page count, their removal does not represent any loss of content from the thesis. Bien que ces formulaires aient inclus dans la pagination, il n'y aura aucun contenu manquant. Canada ii Abstract With new health sciences programs designed to serve northern British Columbia (B.C.), student recruitment will focus on applicants who are likely to remain in northern B.C. long-term. The primary objective of this project was to identify personal characteristics and experiences shared by health care professionals who have worked in northern B.C. long-term to potentially create a northern suitability component for health education program selection criteria. Six speech-language pathologists, 4 psychologists, 4 occupational therapists, 8 social workers, and 4 physiotherapists were interviewed in northern B.C. A qualitative descriptive design was used to identify influences in choosing rural or northern training, initiating practice in northern B.C., and remaining in the region. The findings suggest personal characteristics and experiences, along with age and stage of life, rural background, and location of family influence values about family, career, personal preferences, and community. Personal values determine the decision to come and/or stay in northern B.C. iii Table of Contents Abstract ii Table of Contents iii Acknowledgements iv Chapter 1: Introduction Definitions Selected Health Care Professionals Northern British Columbia Rural and Northern Purpose of This Research Summary 1 2 2 2 3 4 5 Chapter 2: Literature Review Physicians Rural Background and Education Relationships and Community Integration Spousal Contentedness Rural Suitability Recreational Activities and Rural Lifestyle Self Reliance Physicians: Conclusion Nurses Job Satisfaction and Retention Professional and Personal Factors Affecting Job Satisfaction and Retention Community Satisfaction, Job Satisfaction, and Retention Personal Circumstances Personal Opportunities Education Nurses: Conclusion Selected Health Care Professionals Psychologists Occupational Therapists S ocial Workers Across Disciplines Selected Health Care Professionals: Conclusion Summary 7 7 8 12 14 16 16 17 18 18 19 20 21 22 23 23 24 26 26 29 31 33 34 35 Chapter 3: Methodology Objectives Research Questions Design 37 37 38 39 Data Collection Participants Data Analysis Validating the Finding Ethical Concerns Knowledge Translation 41 42 42 43 43 Chapter 4: Results Demographics Geographic Location Spousal and Family Factors Summary Rural Training Recruitment Personal B ackground and Family Factors Professional Factors Individual Factors Community Factors Summary Retention Personal Background and Family Factors Professional Factors Individual Factors Community Factors Summary Characteristics Personal Background and Family Factors Professional Factors Individual Factors Community Factors Summary 45 45 45 48 49 49 51 51 52 55 56 58 59 59 60 63 64 68 69 69 70 73 77 79 Chapter 5: Discussion Choosing Rural or Northern Training Recruitment and Retention Personal Background and Family Factors Professional Factors Individual Factors Community Factors Summary Personal Characteristics and Experiences Personal Values Age and Stage of Life Rural or Northern Background Location of Family Members Summary 80 81 82 84 87 90 91 93 94 96 97 98 99 100 Chapter 6: Conclusion Conceptual Model for Understanding Rural and Northern Suitability Recommendations Health Education Programs Northern B.C. Communities Health Employers Limitations Future Research Summary 103 105 105 107 107 108 109 Ill References 112 Appendix A: Map of Northern B.C. Health Service Delivery Area... 122 Appendix B: The Decision to Stay or Leave 123 Appendix C: Summary of Literature Review Findings 124 Appendix D: Screening Questions 128 Appendix E: Interview Questions 129 Appendix F: Information Sheet and Informed Consent Form 133 Appendix G: Ethical Approval 136 vi Acknowledgements This project has been funded by the Social Sciences and Humanities Research Council of Canada, the Michael Smith Foundation of Health Research, the British Columbia Medical Services Foundation, the McLean Foundation, and the University of Northern British Columbia. Thank you to the private donors who also gave generously to help fund this graduate research through the Yvette and Dollard Bock Health Research Award and Harold Erhard Janzen Scholarship. Thank you to the health care professionals who gave their time to participate in this research. It was only with your interest to participate that I found such success in this project. A sincere thank you to my supervisor Dr. Cindy Hardy for the excellent mentorship she has provided. I could not ask for a more approachable, reliable, and dedicated mentor. I would also like to thank my external auditor, Dr. Karen Dyck, for inspiring this project and taking the time to validate my interpretations. I would also like to extend my gratitude to my committee members, Dr. Martha MacLeod and Dr. Glen Schmidt, for their guidance. I would like to thank my parents, Monty and Heather Manahan, who have facilitated my learning and challenged me to do my best. Thank you to my entire family for providing years of support and enthusiasm for the work that I do. I would also like to thank Nikki Stiles for her continued editorial support and Norm Coyne for his daily encouragements. 1 Chapter 1: Introduction New health education programs with the goal of attracting students who are more likely to stay and practice in rural and northern areas of Canada are opening up across the country (Johnson, Fyfe, & Snadden, 2006). With these programs on the rise, administrators are becoming more and more interested in identifying the factors associated with choosing rural and/or northern practice. Consequently, much of the published literature in this topic area is focused on students or new graduates and their perceptions of rural practice (Arthur, Sheppard, & Dare, 2005). However, high turnover in the rural and northern health sectors emphasizes the need to also analyze the factors associated with staying in rural and northern practice. Exploring the personal characteristics of those health care professionals who have practiced in rural and northern British Columbia (B.C.) long-term will in turn inform recruitment. This thesis highlights, examines, and evaluates the current literature germane to rural recruitment and retention in the health care sector, with a focus on personal characteristics and experiences of physicians, nurses, and other health care professionals in relation to recruitment and retention. This study explores personal characteristics and experiences shared by health care professionals who have lived and worked in northern British Columbia long-term, with the goal of informing potential selection criteria for health care education programs in the future. 2 Definitions Selected Health Care Professionals The University of Northern British Columbia (UNBC) is planning to expand their health sciences programs and has been considering a number of health programs. The health care professions that have been selected for this study have been based on potential health care education programs that may be available or are available in northern B.C. and are designed to address the health care labour market shortages in the region. This study targets the following allied health professions: occupational therapists, physiotherapists, psychologists, social workers, and speech language pathologists. The study focuses on those health care professionals who have lived and worked in northern B.C. long-term. Northern British Columbia The geographic region targeted in this study was the northern part of British Columbia, which is covered and defined by the Northern Health Authority (see Appendix A). Northern B.C. as defined by Northern Health covers approximately 650,000 km and serves nearly 300,000 people, but only includes one community with a population of more than 50,000 (Hanlon & Halseth, 2005). The literature pertaining to health human resources uses various definitions of "northern" and "rural" at different levels of analyses (du Plessis, Beshiri, Bollman, & Clemenson, H., 2001). The longstanding debate regarding what constitutes "rural" and/or "northern" is that some definitions are based solely on geographical boundaries, while others are based solely on social representation, and others use a mixture of both definitions (du Plessis et al., 2001). 3 Rural and Northern For the purpose of this study, the Northern Health definition of northern B.C. is used. However, throughout the document, the terms "rural" and "northern" are used to reference regions outside of northern B.C. There is no standard definition of "rural" or "northern" used in the literature review, as various studies do not clearly define the terms. The terms used by authors of cited sources are retained. Therefore, the use of "rural" and "northern" used to describe areas outside of northern B.C. will remain somewhat obscure, contextual, and relative (Schmidt, 2000). However, the term "rural" is usually classified in terms of population size and density, level of isolation, economic/industrial base of the community, as well as access to health care professionals, resources, and services (Kulig et al., 2008; Public Health Agency of Canada, 2002). The term "northern" usually encompasses a combination of characteristics including remoteness, lack of health care services, and hardship (Schmidt & Klein, 2004). The term "northern" in Canada often embraces the territories, as well as the northern parts of most provinces (Schmidt & Klein, 2004). "Northern" can also encompass a "sense of place", which is created "culturally, economically, and geographically" (Schmidt, 2000, p. 376). The findings from this study could potentially inform both "rural" and "northern" initiatives, but are specific only to northern B.C. Purpose of This Research The Health Council of Canada declared that the recruitment and retention of health human resources is the most pressing challenge facing our health care system (Decter, 2005). The CIHR Institute of Health Services and Policy Research stated in their latest national consultation report that one of Canada's top nationwide research priorities 4 is to learn more about the country's health human resources, and to develop effective recruitment and retention strategies (Gagnon & Menard, 2001). The need to understand health human resources has become increasingly evident at the international, national, and provincial levels. Every province has acknowledged the importance of research that focuses on rural health workforce issues in Canada (Pong et al., 2005). Vacancies in health care occupations: increase wait times, modify delivery approaches, change the roles of personnel, decrease frequency of service, influence service cancellations, and change service eligibility criteria (Teplitsky, 2000). The quality and frequency of health services are heavily dependent on the size, skill, commitment and availability of the health workforce (Poz, Kinfu, Drager, & Kunjumen, 2006). In B.C., numerous initiatives seek to address the current and projected shortage of health care professionals. Recruitment and retention of health care professionals in northern B.C. has been and continues to be a struggle (University of Northern British Columbia Medical Program Community Action Group, 2003). Health care consumers in northern B.C.'s health region claim the vacancies and turnover of health care professionals in their region have negative effects on the care they receive in their communities (Northern Health, 2005). In response to staffing troubles, several recruitment incentive programs, including scholarships and signing bonuses, have been used to attract health care professionals. The University of Northern British Columbia has introduced training programs like the Northern Medical Program, the Nursing Program, and the Social Work programs in response to research that repeatedly suggests that rurally-trained students are more likely to practice in a rural area (Barer & Stoddart, 1992). The application process for these education programs includes an assessment of 5 rural suitability in an attempt to admit those students who are likely to practice in northern British Columbia once they have completed the programs. As a long-term resident of northern B.C. working in early childhood development and care, I became especially interested in the recruitment and retention of long-term health care professionals in the region. From my experience, I hypothesized that longterm health care professionals in northern B.C. shared a number of personal characteristics and experiences, which could in turn inform the selection of students for new health education programs created to serve the region. This study was created to explore the factors influencing training, recruitment, and retention of long-term health care professionals in northern B.C. to inform future recruitment and selection of students. Summary This thesis explores personal characteristics and experiences shared by selected health care professionals who have lived and worked in northern B.C. long-term, and who plan to continue working in the region. The major goal of this study is to identify personal characteristics and experiences to potentially create a suitability component for future health education program selection criteria. The findings from this research will inform health sciences student selection, aid in the future creation of a rural suitability assessment tool, and provide evidence that will inform recruitment and retention strategies for the health sector. Chapter 1 introduces the current study. The literature review is presented in Chapter 2. Chapter 3 describes the methodology used for this study, summarizing the objectives of the study and how they were met. Chapter 4 identifies the results of the study in the factors and themes. The themes are discussed and summarized in Chapter 5. 6 The conclusion is explained in Chapter 6, including a conceptual model for understanding rural and northern suitability. Recommendations for health education programs, northern B.C. communities, and health employers, as well as the limitations and future directions for research are also presented in this final chapter. 7 Chapter 2: Literature Review This literature review summarizes the current literature relevant to rural and northern recruitment and retention in the health care sector. The review has a special focus on personal characteristics and experiences of physicians, nurses, and other health care professionals in relation to recruitment and retention. The literature review includes rural suitability research pertaining to physicians, nurses, psychologists, occupational therapists, social workers, and other health care professionals. Although physicians and nurses are not the focus of this study, the majority of literature related to health human resources recruitment and retention in rural areas targets these professions. Therefore, the literature review contains both physician and nurse recruitment and retention literature to inform the current study. Physicians Finding physicians to serve rural areas is a problem around the world and consequently the majority of literature pertaining to rural suitability is focused on the medical profession. Although the proposed study will focus on other selected health professionals, a review of the literature relevant to physicians will inform the current study. In Canada, according to census and Canadian Medical Association [CMA] data, small towns with populations fewer than 10,000 people are home to approximately 22.2% of Canada's total population but only 10.1% of Canadian physicians work in these rural communities (Society of Rural Physicians of Canada, 2006). Data also indicate regional centers with populations between 10,000 and 100,000, which often provide health services for rural areas, make up 15.9% of the Canadian population. However, only 11.9% of Canada's physicians work in these regional centres (Society of Rural 8 Physicians of Canada, 2006). A study using 1996 census data suggests the average B.C. physician-to-population ratio is 1.06 to 1,000 residents, well below the minimum ratio Barer and Stoddart (1991) recommend of 1.9 to 1,000 (Thommasen, Gryzbowski, & Sun, 1999). The same study finds 65% of B.C. rural communities assessed have physician-to-population ratios less than the provincial average, while all northern B.C. regions have lower ratios than the provincial average (Thommasen et al., 1999). Pong and Pitblado (2006) suggest the count of rural physicians underestimates the unequal distribution of the physicians in rural and urban regions of Canada and that these statistics do not necessarily represent the true shortfall. Rural Background and Education Recruiting physicians in rural areas has proven difficult for many years. As a result, the most extensive body of research literature on the recruitment of rural health professionals is focused on physicians. A group of researchers at the Florida State University completed a systematic review of articles assessing the factors related to the recruitment and retention of primary care physicians in rural communities (Brooks, Walsh, Mardon, Lewis, & Clawson, 2002). The researchers used PubMed and Medline databases to find 21 articles that fit the criteria. According to the review, rural upbringing has a positive influence on the decision to practice rural medicine and is the best predictor of recruitment documented in the literature (Brooks et al., 2002). One methodologically strong study in the review (Rabinowitz, Diamond, Hojat, & Hazelwood, 1999), a cohort design with controls (N = 1,609), used multivariate analysis to determine that growing up in a rural area was the most robust predictor of choosing rural practice (Brooks et al., 2002). According to the study by Rabinowitz and colleagues 9 (1999), choosing family practice over other specialties was also a stout predictor for rural practice (Brooks et al., 2002). According to the existing evidence found in this review, training factors such as rural curriculum and residency in rural communities positively correlate with recruitment of physicians to rural areas (Brooks et al., 2002). However, a systematic literature review focused on 'rural exposure' and 'rural placements' in hopes to further understand the influence of these factors on the uptake of rural practice in Australia (Ranmuthugala et al., 2007). The researchers found that training environments, including curriculum and residency, influence new graduates' decision to practice rurally. However, these researchers also highlight the inconsistencies throughout the literature pertaining to how specific characteristics of rural training, such as length, frequency, timing, and level (undergraduate or graduate) of exposure affect the uptake of a rural career (Ranmuthugala et al., 2007). The Australian research group emphasized the need to adjust for possible confounding variables when looking at the impacts of rural exposure on the decision to practice in a rural area (Ranmuthugala et al., 2007). The most prominent finding is the relationship between rural background and choosing rural medicine. Canadian researchers, Easterbrook et al. (1999), completed a cross-sectional survey of 159 physicians who had graduated from Queen's University in Ontario. The results of the study show physicians raised in rural communities were 2.3 times more likely than those who were not raised in rural communities to choose rural practice after graduation. The findings illustrate that those physicians raised in rural areas were also 2.5 times more likely to stay in rural practice. Unlike the many studies reviewed by Brooks and colleagues (2002), Easterbrook et al. (1999) did not find an 10 association between rural education and choosing rural practice. Easterbrook et al. (1999) also did not find significant associations between gender or age and choosing rural practice. The authors note that one of the major limitations in this study is the low statistical power and the potential inability to detect small associations (Easterbrook et al., 1999). The findings suggest no significant association between rural education and choosing rural practice do not agree with much of the literature, reinforcing concerns about low statistical power (Easterbrook et al., 1999) A literature review conducted for the Northern Medical Program in Northern B.C. highlighted studies all over the world that identify rural origin as the most significant factor for predicting rural medicine practice (Johnson et al., 2006). Unfortunately, rural students are often under-represented in medical schools (Johnson et al., 2006). Dhalla et al. (2002) found first-year medical students were more likely to have highly-educated professional parents when compared to the general Canadian population (Rourke, 2005). The Task Force of the Society of Rural Physicians notes that rural people are more likely to have less education than their urban counterparts; thus the younger rural generation has a lower likelihood of having parents with a higher education (Rourke, 2005). Rourke (2005) discusses the possibility that young rural people are therefore also less likely to have role models with higher education and potentially not as encouraged to pursue a higher education in comparison with their urban counterparts. An older Canadian study found that rural high school education, having a spouse with a rural background, and having a father who is either a farmer or a health care professional were all personal factors related to rural medicine practice (Dial & Lindley, 1987). 11 Many studies allude to personal characteristics and experiences as having positive impacts on physicians' decisions to practice in rural or Northern communities (Barer & Stoddart, 1999; Thommasen, Van Der Weyde, Michalos, Zumbo, & Hagen, 2003). Laven and Wilkinson (2003) completed a systematic review of observational cohort or case studies that compare doctors working in rural and urban areas, and others that followed doctors or students over time. Only 12 studies fit the criteria, but each one of the studies included in the review suggested the likelihood of working in rural practice is approximately twice as great for those physicians who have a rural background (Laven & Wilkinson, 2003). The researchers found rural schooling (location of elementary and/or high school) and having a partner of rural origin was also associated with rural practice, but these factors were identified in fewer than half of the studies (Laven & Wilkinson, 2003). Rural undergraduate and postgraduate training were also found to be associated with rural practice in four of the five studies that reported on the influence of training location (Laven & Wilkinson, 2003). Chan, Crichton, Rourke, and McCready (2005) mailed out surveys to 651 rural family physicians in Canada. Chan and colleagues (2005) had 382 respondents from both urban backgrounds (n = 240) and rural backgrounds (n = 122). The survey responses suggested rural training, such as rural curriculum and residency, affects the decision to work in rural practice, but rural training has a more powerful impact on those from urban backgrounds (Chan et al., 2005). The researchers suggested those students with rural upbringing already have much more interest in rural practice before training and therefore rural training has more influence on those from urban backgrounds. The survey responses also suggested financial incentives, proximity to family in rural areas, and spouses' 12 interests in rural lifestyle have an impact on deciding to practice rurally. Physicians identified "the challenge of rural medicine" and "enjoy a rural lifestyle" as the most important factors in deciding to practice rural medicine (Chan et al., 2005). Other influential factors include recruitment by specific communities and the appreciation of working with rural people. The researchers noted the potential for respondent bias in this study and the difficulty ensuring that each of the respondents had the same definition or baseline for each of the factors evaluated (Chan et al., 2005). Relationships and Community Integration Inter-personal relationships, social networks, and community participation also influence the duration of rural practice (Barer & Stoddart, 1999; Pathman, 2006; Sempowski, Godwin, & Seguin, 2002). A recent Ontario study used a cross-sectional survey to identify and compare characteristics shared by physicians who left rural practice after less than three years ("short-term" physicians) to those shared by physicians who practiced more than seven years ("long term" physicians) in the same rural area. Sempowski et al. (2002) surveyed 234 Ontario physicians, working in a specified area, identified through the College of Family Physicians of Canada database, 1999-2000. The participants were divided into two groups based on how long they had practiced in a rural area, namely short term (n = 62) and long term (n = 172). Every participant was mailed a survey which inquired about their current community, demographics, personal background, education, work environment, job satisfaction, and the level of satisfaction with community, remuneration, and access to locums and continuing education resources (Sempowski et al., 2002). 13 Findings suggested physicians in the long-term group were more likely to be male, to be older, to have children living with them at home, and to have happier spouses (Sempowski et al., 2002). The long-term physicians were also more likely to feel less socially isolated, have more access to professional support, and have access to continuing education. The major limitation to this study was the potential selection bias as only 57% of rural Ontario physicians were members of the Canadian College of Family Physicians at the time and only members were sampled, suggesting possible decreased generalizability (Sempowski et al., 2002). However, the study is helpful in assessing how personal characteristics and experiences may influence duration of rural health practice. The concepts of self, community, belonging to a community, and feeling needed are all considered to be important factors in determining physicians' duration of rural health practice (Cutchin, 1997; Lahaie, 1991; Mayo & Mathews, 2006). Hays, Wynd, Veitch, and Crossland (2003) identified attitudinal factors that influence duration of rural practice by interviewing 13 physicians in Australia who had been part of a larger study nine years prior. The larger previous study had used a random selection process to select a stratified sample from the 140 doctors in rural Queensland in 1991. The 13 participants from the previous study were those who could be contacted, were still living in a rural area, and agreed to participate. The telephone interview inquired about professional plans for the future, what might make them want to leave rural practice, why they had stayed in the community, what changes had taken place in their practice over the past decade, and how (if at all) government initiatives had affected their decision or practice. Approximately 38% of the participants stated they were stressed and unhappy at the time of the interview. Factors that appeared to be related included heavy workload, 14 lack of educational opportunities for family, and professional isolation (Hays et al., 2003). The physicians expressing the greatest stress also reported the greatest perception of professional isolation and little support from professional networks. The results indicated that the availability of professional networks, locum support, and the ability to take vacation time or days off influence duration of stay in a rural area (Hays et al., 2003). The researchers found that retention is not influenced by funds for relocation, training, family support, job-share programs, or rural clinical placements for undergraduate students (Hays et al., 2003). The authors concluded that support networks, both social and professional, influence duration of rural practice and this, in turn, affects the creation and sustainability of those networks (Hays et al., 2003). Hays et al. (2003) also reported that duration of and satisfaction with rural health practice affects the physicians' perceptions of rural life. Findings from this research suggested physicians who stay in rural areas for a long period of time find social networks, feel like they have become part of the community, and create professional support systems for themselves (Hays et al., 2003). Spousal Contentedness These conclusions about the complex inter-relationship between personal characteristics, experiences, and rural retention have been further validated with Canadian research on physician spousal contentedness (Mayo & Mathews, 2006). A personal factor that has been repeatedly reported as a major influence on duration of rural practice for physicians is how their spouse feels about rural living (Barer & Stoddart, 1999; Pathman, 2006; Sempowski et al., 2002). Mayo and Mathews (2006) used qualitative methods to identify factors that affect spousal contentedness and how, in turn, 15 spousal contentedness influenced job satisfaction and duration of rural practice. They interviewed the spouses of 13 rural physicians in Newfoundland and Labrador. The interview questioned their motivation to move to their current location, their motivation to plan to move away if applicable, and other questions about what it was like for them to live in a rural area. As interviews continued, additional questions were asked to qualify and extend interview themes, and interviews were analyzed using a grounded theory approach (Patton, 2002) with a constant comparative method of analysis (Mayo & Mathews, 2006). Findings suggested that physicians' spouses who are content are more likely to want to stay in their community and therefore positively affect physician retention (Mayo & Mathews, 2006). The spouses generally defined their contentment in terms of their sense of satisfaction with their community, feeling comfortable in their community, and not feeling bored or isolated. Community integration, spousal employment opportunities, the spouse's rural background or experience living in rural communities, and personal support networks were all factors found to have a positive influence on spousal contentment (Mayo & Mathews, 2006). Discontent was reported by those spouses who came from very different cultures, who were interested in extracurricular activities that were not available in their community and who were not living close to their family and friends (Mayo & Mathews, 2006). The interplay of family and community factors provided valuable insight into the retention of rural physicians. This study begins to show the characteristics of physicians who not only come to a rural areas, but remain in a rural communities. 16 Rural Suitability With the creation of the Northern Medical Program at UNBC, the likelihood of students choosing rural practice and remaining in rural communities after graduation has become relevant to the program application process (Johnson et al., 2006). Based on research literature and focus groups, the Northern Medical Program created a Rural Suitability Scale on which applicants are scored on their northern background or experience, self-reliance, and recreational preferences (Bates, Frinton, & Voaklander, 2005). The applicants are given points according to the amount of time spent in rural communities, the population size of the communities, and the number of experiences living in the small communities (Johnson et al., 2006). Based on research findings, applicants are given a special advantage in the application process if they grew up in a rural community, but also earn points if they have rural family connections, role models in rural areas, and/or positive attitudes toward rural practice (Johnson et al., 2006). Applicants are also given recognition if they have had rural exposure in training or in their previous curriculum (Johnson et al., 2006). Recreational Activities and Rural Lifestyle The Rural Suitability Scale pays attention to the applicants' recreational activities. Similar to other rural medical education programs, applicants are evaluated based on the remoteness of their activities, the time involved in those activities, and the potential risk of participating in these activities (Johnson et al., 2006). The evaluation factor suggests that those applicants who enjoy activities available in rural communities, such as fishing, skiing, or hiking would be more likely to stay in a rural community (Johnson et al., 2006). According to anecdotal evidence from other medical programs and the focus 17 groups done at the Northern Medical Program (Bates et al., 2005), applicants who are very involved in recreational activities only found in urban centers are potentially not as suitable for rural medicine (Johnson et al., 2006). Congruent with the preceding literature review, an appreciation of "rural lifestyle" is considered a predictor of rural practice. Enjoying a rural lifestyle and/or seeking a "relaxed" lifestyle have been identified as potential factors in relation to duration of rural practice, consequently becoming valued on the Rural Suitability Scale (Johnson et al., 2006). The Northern Medical Program found that appreciating rural lifestyle was identified in both the literature (Crump, Barnett, & Fricker, 2004; Kearl & Mainous, 1992) and in the focus groups on rural suitability (Bates et al., 2005). However, as Johnson and colleagues (2006) have pointed out, the definition of rural lifestyle has not been clearly identified, making it difficult to make any predictions of retention based on this factor. Self Reliance The focus groups conducted during the development of the Northern Medical Program Rural Suitability Scale suggested the personal quality of self reliance could predict choosing rural practice (Bates et al., 2005; Johnson et al., 2006). The Northern Medical Program uses a ten point scale to assess self reliance including level of independence in past work experience, ability to make decisions independently, and maturity (Bates et al., 2005; Johnson et al., 2006). Other rural medical school application processes have similarly used maturity, independence, conscientiousness, self directed learning, and ability to manage own life situations as potential predictors of choosing rural practice (Johnson et al., 2006). According to a literature review done by the 18 Northern Medical Program, the influence of self reliance and other characteristics, such as maturity and independence, in relation to predicting rural practice are still considered to be anecdotal and have yet to be documented in the research literature (Johnson et al., 2006). Physicians: Conclusion The literature on the rural physician workforce provides insight into factors that influence decisions to practice and remain working in rural areas. Rural background is the strongest influence in both recruitment and retention of rural physicians. Rural exposure during undergraduate and graduate training, including both rural curriculum and residency, also shows some influence on recruitment and retention. Family factors, such as having family in rural communities and proximity to family, inspire recruitment and retention of rural physicians. Spousal characteristics, including spouses' rural experience and contentedness in rural communities, impact physicians' decisions to choose and settle in rural areas. Community integration for both the physician and the spouse promotes retention for rural physicians. Furthermore, personal characteristics such as having rural role models, interest in rural lifestyle, and enjoying the challenge that rural work in medicine offers all have some impact on decisions to begin and stay in rural practice. However, the level of influence that specific personal factors have on the decisions to choose and remain working in rural practice needs more exploration. Nurses Research on the recruitment and retention of rural physicians is helpful to understand the current and upcoming shortages of health care professionals including but not limited to physicians in rural and northern Canada. However, Pong and Russell 19 (2003) note that similar research on other rural health care providers has received very little attention. Every health discipline may have a different set of issues and factors that relate to recruitment and retention in rural areas (Pong & Russell, 2003). Even in nursing, the country's largest group of health care professionals, literature discussing potential predictors of rural practice is hard to find (Pong & Russell, 2003). Nurses are often considered the foundation of the Canadian health care system and understanding nurse retention is necessary to the analysis of health care service quality, efficiency, and sustainability (MacLeod et. al., 2004; Pong & Russell, 2003). The unequal distribution of the nursing workforce between rural and urban areas is well documented (MacLeod et al., 2004). The World Health Organization states over 60% of the world's nurses work in urban areas, suggesting a significantly unequal distribution of nursing service in rural areas (Poz, et al., 2006). Assessments of Canada's nursing workforce show only 18% of registered nurses are serving the 22% of Canadians who live in rural areas (MacLeod et al., 2004). It is also more difficult to recruit nurses in rural regions. A study at the University of Colorado suggests it takes nearly 60% longer to recruit nurses to rural facilities than to urban facilities (MacPhee & Scott, 2002). Despite the importance of rural nurses to the health care system and the evident regional disparities, there has still been little research that explores the retention of rural nurses (MacLeod et al., 2004). Job Satisfaction and Retention There are limited studies identifying the influence of personal characteristics and experiences on rural practice duration for nurses in British Columbia (Stewart et al., 2005). Understanding the relationship between job satisfaction and duration of practice 20 could be one of the best ways to begin trying to understand the retention of the rural nursing workforce. Pan, Dunkin, Muus, Harris, and Geller (1995) used a logit analysis of international survey data of 2,509 rural registered nurses. Results suggested job satisfaction is the most influential predictor of staying in rural practice (Pan et al., 1995). Ingersoll, Olsan, Drew-Cates, DeVinney, and Davies (2002) explored the factors interrelated with job satisfaction and retention by conducting a correlation analysis on both demographic and job satisfaction data. The researchers found nurses with higher levels of education are more satisfied with their jobs, as are nurses who are in educator roles or management roles, while part-time and per-diem nurses are less satisfied (Ingersoll et al., 2002). There was also a strong positive correlation between job satisfaction and professional autonomy, organizational commitment, pay scale, and task requirements (Ingersoll et al., 2002). Ingersoll and colleagues (2002) noted a number of study limitations. They reported a poor survey response rate in the study (46%) and identified difficulties generalizing the data because the sample included only registered nurses (Ingersoll et al., 2002). Future research needs to aim for higher response rates, and must include a variety of nursing professions to increase generalizability. Nonetheless, this study lends valuable insight to rural nurse job satisfaction and retention. Professional and Personal Factors Affecting Job Satisfaction and Retention Hegney, McCarthy, Rogers-Clark, and Gorman (2002) looked into the retention of rural nurses in Australia. The researchers conducted a cross-sectional survey of 146 registered and enrolled nurses, asking them to rank 91 separate items on level of importance in relation to the decision to remain in rural practice. The results suggested job satisfaction and being part of a professional team are the most important job-related 21 predictors of remaining in rural practice (Hegney et al., 2002). The researchers identified that those nurses who remain in rural practice generally appreciate "rural lifestyle", feel a sense of belonging in the community, and work in a family-friendly environment (Hegney et al., 2002). The findings suggested professional support networks, managerial support, professional autonomy, maintenance of clinical skills, and peer recognition are very important in their decisions to stay (Hegney et al., 2002). Hegney and colleagues (2002) also noted that availability of social support networks, having friends in the community, personal respect for the rural community, and availability of opportunities for education and training were all influential in the decision to stay in rural practice. The study introduces the inter-relationship between personal characteristics and job satisfaction, as well as the importance of community satisfaction in the decision to stay in rural nursing practice. Community Satisfaction, Job Satisfaction and Retention Researchers Henderson-Betkus and MacLeod (2004) recently surveyed 124 public health nurses in rural, northern British Columbia. The survey analysis indicated that job satisfaction is most influenced by professional status, professional interactions, and autonomy (Henderson-Betkus & MacLeod, 2004). However, the researchers noted job satisfaction for rural nurses occurs within the context of community satisfaction (see Appendix B). Henderson-Betkus and MacLeod (2004) suggested rural nurses can only be satisfied with their job if they are satisfied with their community. Rural nurses in the study stated that the level of friendliness in the community, their number of friends in the community, and level of trust they feel toward the community influence community satisfaction (Henderson-Betkus & MacLeod, 2004). Similar to Hegney and colleagues 22 (2002), this study indicates having friends living in rural communities, having a sense of belonging in the community, and having access to social networks are important predictors of retention. Henderson-Betkus and MacLeod (2004) noted rural nurses report social/recreational opportunities, safety, and quality of schools increases community satisfaction as well (Henderson-Betkus & MacLeod, 2004). Personal Circumstances Henderson-Betkus and MacLeod (2004) found the relationship between job satisfaction, community satisfaction, and the decision to leave or stay is interrupted by a number of "filter factors". The researchers found that even if rural nurses are satisfied with their jobs and their community, a collection of personal characteristics and experiences, or "filter factors", still determine the decision to remain in rural practice (see Appendix B). Personal circumstances acting as "filter factors" include retirement, financial needs, family needs, family commitments, and professional growth (HendersonBetkus & MacLeod, 2004). Nearing retirement influences nurses to stay in their current position for security; however, if their spouse is retiring, the nurse is more likely to leave (Henderson-Betkus & MacLeod, 2004). Financial needs influence nurses to stay, but also influence nurses to leave if their spouses can not find employment (Henderson-Betkus & MacLeod, 2004). Family needs and commitments can influence nurses to stay, but can also influence them to leave if family lives elsewhere (Henderson-Betkus & MacLeod, 2004). Henderson-Betkus and MacLeod (2004) noted nurses who have children or spouses who want post-secondary education that is not available in the community are more likely to leave. As seen, the decisions to stay are often very complex, and contingent on individual circumstance, as well as personal opportunities. 23 Personal Opportunities Opportunities like shifts in the economy, real-estate, and job availability for self and spouse, as well as employment benefits act as "filter factors" (Henderson-Betkus & MacLeod, 2004). Researchers noted rural nurses are more likely to leave the community if there are drops in real-estate prices or other economic misfortunes. Henderson-Betkus and MacLeod (2004) showed rural nurses are more likely to leave a community if the primary industry is suffering. The researchers found spouses' employment to be a major predictor of retention, and suggested retention may be more dependent on spousal employment than on personal job or community satisfaction (Henderson-Betkus & MacLeod, 2004). Loss of benefits, another opportunistic factor, describes the loss of seniority and other employment benefits if a nurse transfers to another community. Henderson-Betkus and MacLeod (2004) found nurses stay in rural communities even if they are not satisfied with the job or the community, in order to prevent loss of employment benefits (Henderson-Betkus & MacLeod, 2004). Demographic factors including spouses' occupations act as "filter factors" (Henderson-Betkus & MacLeod, 2004). The majority of nurses who participated in this study were married, and were working in small towns because of their spouses' jobs (Henderson-Betkus & MacLeod, 2004). These personal opportunities and opportunities for spouses impact the decision to stay or leave. Education In contrast to many physician studies, the findings by Henderson-Betkus and MacLeod (2004) revealed education or training placements in rural areas, are not related to long-term rural practice. One of the most powerful predictors of rural practice, 24 according to Henderson-Betkus and MacLeod (2004), is having family living in a rural area. Also, personal feelings about wanting to raise a family in a rural area are considered predictors of rural practice (Henderson-Betkus & MacLeod, 2004). This finding is similar to other research studies focussed on rural nursing. Bushy (2002) studied rural nurses in Canada, U.S.A., as well as Australia and found rural background and family connection to community were predictors of rural nurse retention in all three countries. These findings echo those by Hegney, Pearson, and McCarthy (1997) who also uncovered this in an effort to identify the role and function of rural nurses in Australia. Based on this research, Hegney and colleagues (1997) suggest rural nurses are generally from rural backgrounds, but trained in urban education facilities. They are not specifically trained as rural nurses and become rural nurses because they go back to work in rural areas for family or lifestyle reasons (Hegney et al., 1997). The findings pertaining to rural health education suggest investigation into the impact of rural-focused training programs on recruitment and retention. Nurses: Conclusion Although the research specific to rural nursing is growing, it is still very limited (MacLeod et al., 2004). Most of the work that has been done explores professional characteristics and factors related to job satisfaction. It appears job satisfaction and community satisfaction are major predictors of staying in a rural community. However, there seem to be associations between job satisfaction, community satisfaction, personal characteristics, experiences, and retention. Similar to physicians, nurses with a rural background and an appreciation for rural lifestyle are more likely to be satisfied with their jobs and are likely to continue working in rural communities. Similar to physicians, 25 nurses who become involved in their rural community and are satisfied with their rural community stay working in rural practice. According to the literature, having friends in the community and a strong social network impact both job satisfaction and retention. Unlike physicians, nurses identified financial incentives and inexpensive housing as retention factors. This finding may be explained by the differing payment schemes for these two professions. Nurses are salaried, while physicians follow a fee-for-service pay and are generally paid more than nurses. Nurses also identified the opportunities for career advancement and employment opportunities as retention factors and physicians did not. Again, this could be explained by the different educational and income levels associated with these two occupations. Overall, the literature suggests nurses who have family and friends in rural communities are more likely to stay in these communities. Similar to physicians, the nursing literature draws attention to the importance of having a spouse who has career opportunities in the region and appreciates living in rural and/or northern communities. Spousal contentedness was identified as a major influence on retention in the physician literature, but was not apparent in the nursing research literature. Some of the nursing research highlights that nurses in the past have predominantly been female and they have followed their spouses to rural and/or northern communities. This particular finding was not evident in the physician literature. Although a gender analysis may shed light on these differences, little of the literature reviewed has clearly assessed gender differences in the analysis or interpretations. Lastly, most of the physician literature suggests rural curriculum and practicum opportunities increase both recruitment and retention. However, more recently 26 researchers have noted that certain characteristics of rural training should be analyzed for their specific effects on long-term retention. Nursing literature highlights the importance of both rural curriculum and practicum on recruitment, but the literature does not clearly identify an influence on retention. Overall, the level of influence that specific personal, professional, and community factors, as well as rural-focused training programs have on the decisions to choose and remain working in rural practice needs further exploration. Selected Health Care Professionals There has been little research to assess personal characteristics and experiences in relation to duration of rural practice for nurses, and even less for other health care professionals in Canada, such as those selected for this study. The health care professions selected for the current study are based on the potential health care education programs that may be made available or are available at UNBC, including psychologists, physiotherapists, occupational therapists, speech language pathologists, and social workers. The following section reviews the limited literature pertaining to the personal characteristics and experiences of these selected health professionals in relation recruitment and retention. Unfortunately, a small number of relevant studies were revealed and only research on psychologists, occupational therapists, social workers, as well as a couple of interprofessional studies were found. Psychologists Recently, three rural psychologists presented at the Canadian Psychological Association Annual Conference (Dyck, Haugen, & Cornock, 2007) to discuss the benefits of working in rural psychology and to potentially recruit students to a rural-focused internship program. Each psychologist discussed the characteristics they believed 27 influence success in rural psychology. Similar to research on retention of rural physicians, Dyck and her colleagues (2007) suggested that psychologists with a rural background are more likely to practice in rural areas. Based on their own experiences working with psychologists in rural Manitoba, they agreed that positive rural experiences, such as internships, mentorship, and education in rural settings increase the likelihood of rural practice (Dyck et al., 2007). The rural psychologists noted that long-term rural psychologists tend to enjoy community-based work over hospital-based work, to appreciate variety at work, and to welcome interdisciplinary work opportunities (Dyck et al., 2007). The psychologists also suggested that long-term rural psychologists enjoy the "rural lifestyle", have spouses who are able to find work in rural areas, and have personal connections to rural and northern communities (Dyck et al., 2007). In 2005, Dyck presented other anecdotal suggestions at the University of Northern British Columbia to recruit potential graduate students to a rural psychology training program. Dyck suggested that rural psychology is broad, varied, and often involves outreach work. Therefore, a successful, long term, rural psychologist would need to be comfortable working alone, have a broad range of skills, and be confident in their abilities. A rural psychologist needs to have good time management skills, be organized, trustworthy, approachable, and "down to earth". Dyck suggested that rural psychologists need to be able to relate to their clientele, so having substantial experience living in a rural area is positive. Rural psychologists also need to have respect for other disciplines and be resourceful when working with the limited resources often found in rural and northern communities. Rural people often ask personal questions, and rural psychologists 28 have to be comfortable responding to them, be flexible, and be open to doing things differently (K. Dyck, personal communication, 2005). Although these anecdotal suggestions have yet to be further investigated, there are several studies focused on the ethics of dual relationships in rural psychology that touch on many of the factors discussed by Dyck and her colleagues (2007). Many clinical psychologists are trained in urban settings, where having contact with a client outside of the practice is frowned upon. However, these dual relationships are often inevitable in rural settings. Campbell and Gordon (2003) highlighted the difficulties associated with the dual relationships psychologists find in small, rural communities. The researchers noted that rural health care professionals often have overlapping personal and family relationships with their clients (Campbell & Gordon, 2003). The researchers suggested that successful rural psychologists are those who recognize overlapping relationships, yet become part of their community's social construct (Campbell & Gordon, 2003). Campbell and Gordon suggested that rural psychologists can not be "outsiders", and must accommodate the local norms and power structures found within the rural community. Through their work on dual relationships, Campbell and Gordon (2003) identified the need to investigate the characteristics of psychologists who are able to succeed in a rural environment. At the end of their research, Campbell and Gordon (2003) hypothesized that successful rural psychologists are: comfortable with a "rural lifestyle", likely to have grown up in a rural environment, able to integrate into the community, general practitioners with a broad scope of practice, comfortable with a relatively high profile in their community, and have a high tolerance for the blurring of personal and professional boundaries. Occupational Therapists There have also been limited studies that explore personal characteristics and experiences in relation to the retention of rural occupational therapists. Wills and CaseSmith (1996) used ethnographic methods to identify shared experiences and the roles shared by occupational therapists working in rural school settings. The researchers interviewed occupational therapists (n = 6) in the U.S.A. and discovered five emergent themes. The researchers suggest that the therapists working in rural schools are: generalists, bridge health services gaps, belong to a strong peer support network, use integrated team approaches to service, and often can not do everything they want to do in their practice because of the lack of resources (Wills & Case-Smith, 1996). The participants identified that occupational therapists working in rural areas are creative, resourceful, self-reliant, and have a solid support network (Wills & Case-Smith, 1996). This study was exploratory and needs to be replicated, but it is one of the first studies to identify personal characteristics and experiences shared by rural occupational therapists. In another ethnographic study of Australian occupational therapists that had left rural practice, researchers found a number of interrelated professional, environmental, and personal factors determined the therapists' departures (Mills & Millsteed, 2002). The findings suggested that a spouse's unhappiness or desire to relocate was one of the top reasons for leaving rural practice (Mills & Millsteed, 2002). Other personal reasons included lack of education for children, reluctance to settle down, desire to reunite with family, and burnout. Professional reasons identified by the participants included the lack of professional peer support and inability to continue education, advance their careers, or take time off for travel (Mills & Millsteed, 2002). The limitations of this study include limited generalizability, as well as potential recall bias because many of the therapists had spent many years away from rural practice at the time of the interviews. However, Mills and Millsteed's (2002) findings about retention of occupational therapists in rural areas resemble those findings on the retention of rural physicians in Canada discussed earlier. More recently, a qualitative Australian study was completed to identify why occupational therapists had chosen to work in rural areas (Devine, 2006). Using a phenomenological approach, Devine (2006) and a group of third year occupational therapy students conducted 10 interviews with occupational therapists (n = 6) working in rural areas, and university program coordinators (n = 4) from a rural occupational therapy program. The interviews suggested that occupational therapists chose rural practice because they wanted to work in a multidisciplinary team environment. The interviews also highlighted that the occupational therapists who chose rural practice wanted greater responsibility, a broader scope of practice, and more personal autonomy (Devine, 2006). Participants identified that occupational therapists were more likely to choose rural practice if they had previously lived or worked in a rural area. They also suggested that marrying someone in the rural area, having friends or family in the area were also motivating factors for choosing rural practice (Devine, 2006). Some participants also cited a "passion" for rural practice, the ability to be creative and professional autonomy as reasons for choosing rural practice (Devine, 2006). Similar to Mills and Millsteed (2002), the participants suggested that challenges and potential reasons for leaving rural practice included inability to take time off, difficulties finding professional peer support, job burnout due to workload, and inability to continue education (Devine, 2006). Participants suggested that rural occupational therapists needed to have sound time 31 management and organizational skills, and to be realistic and efficient. Participants further noted that rural occupational therapists are able to prioritize their work and develop stress management skills (Devine, 2006). This study offered rich, informative data on the recruitment of occupational therapists in rural areas, as well as insight into the potential areas needed to be investigated in the retention of rural health professionals. However, this study is exploratory, had a very small sample size, and likely contains regional biases (Devine, 2006). Social Workers There have been very few longitudinal studies of allied health care professional recruitment and retention. Recently, Lonne and Cheers (2000) presented their findings from a longitudinal study on rural social workers at the International Conference on Rural Communities and Identities in the Global Millennium, in Nanaimo, B.C. Lonne and Cheers (2000) had 123 newly-appointed social workers fill out a questionnaire every 3 months for over 2 years. The researchers found the most common motivations identified by the participants for taking their rural positions were: career advancement, desire to work in the rural field, appreciation of "rural lifestyle", and spouses' job (Lonne & Cheers, 2000). The researchers noted a high rate of turnover, but also recognized that job satisfaction, community satisfaction, lower community visibility, and local friendships all increase retention (Lonne & Cheers, 2000). They also noted that older social workers who enjoy the "rural lifestyle" and have past experience in a rural community report less job anxiety, and consequently stay in the rural communities longer (Lonne & Cheers, 2000). Two unpublished descriptive phenomenological studies conducted at the University of Northern British Columbia in the Social Work Program also found similar findings. Peterson (1996) explored the lived experiences of 7 social workers who had stayed working in northern British Columbia for an average of 9.14 years. Peterson (1996) identified several personal attributes associated with staying in northern B.C. as a professional social worker and suggested that the character of the person needs to match the character of the community. The participants suggested that a professional social worker who stays working in northern B.C. loves the northern lifestyle, works with integrity, values northern people, and their communities. Participants also suggested that a social worker living in northern B.C. is optimistic, genuine, personable, compassionate, mature, innovative, self-sufficient, community-minded, trustworthy, open, honest, flexible, adaptable, caring self-aware, straight forward, upfront, and comfortable with dual relationships with clients (Peterson, 1996). Peterson (1996) suggested that social workers who stay in northern B.C. already have natural abilities, people skills, and rural life experience that they then integrate into their professional practice. More recently, Mackenzie (2006) at UNBC interviewed 7 social workers who were working in small Yukon communities and 5 social workers who had left the Yukon after working in similar communities. Using the same approach as Peterson (1996), Mackenzie (2006) extrapolated four major themes in regards to personal attributes that help or support social workers who practice in small town Yukon. The analysis unveiled that social workers are best suited to work in the Yukon when they are (1) willing to establish relationships in the community, (2) willing to maintain boundaries for self care and be visible in the community, (3) flexible and creative, and (4) thriving on a sense of 33 independence. Mackenzie (2006) identified autonomy, self-motivation, independence, generalist practice, flexibility, creativity, and willingness to develop relationships with community members (clients, politicians, friends) as potential predictors of success for social workers in the region. Similarly, Schmidt and Klein (2004) completed 16 focus groups with social workers and 27 interviews with social work supervisors in both rural and urban Canadian communities. The study focused on both the strengths and challenges of working in both rural and urban geographic regions to inform retention strategies. The findings suggest a number of personal differences between rural and urban social workers. Rural social workers named family and community connections as benefits of staying in their current practice more often than urban social workers (Schmidt & Klein, 2004). Social workers in rural regions suggested they valued professional autonomy and a generalist approach to social work, while those in urban regions did not (Schmidt & Klein, 2004). Unlike urban social workers, social workers in rural regions identified the time they saved not having to drive in traffic as a benefit to practicing in rural areas, as well as being close to the wilderness and outdoor recreational opportunities (Schmidt & Klein, 2004). Across Disciplines Daniels and colleagues (2007) performed a multivariate analysis on longitudinal survey data they had collected on graduates for a variety of allied health care programs in New Mexico. The programs included medicine, nursing, pharmacy, physiotherapy, occupational therapy, dental hygiene, respiratory therapy, speech pathology, public health, physician assistant, social work, and medical laboratory sciences. The researchers established that the size of the professional's childhood community, participation in a rural practicum, choice of discipline, and age at graduation were all associated with rural practice. Daniels et al. (2007) identified that the decision to practice in a rural community was based on community need, financial aid, the size of the community, as well as whether or not the professional participated in a rural training program and if they were returning to their hometown. The researchers found that staying in rural practice was more likely if the professional was originally from that community, and if the size of the i community was in line with their personal preferences (Daniels et al., 2007). Schofield and colleagues (2007) in New South Wales Australia recently released the "Careers in Rural Health Tracking Survey". Based on an extensive literature review, consultation with rural clinicians, and pilot surveys with students, this group of researchers created a longitudinal survey to question rural health students in medicine, nursing, and other allied health professions. The survey will be given to approximately 500 students annually for 10 years and the results will be used to identify the factors that influence the decisions to practice in rural areas, to stay working in rural areas, and to assess the differences among the various health professions (Schofield et al., 2007). The survey is based on the recruitment and retention literature for medical, nursing, and other allied health care professions. The factors identified in the survey could be used for more short-term studies on retention. However, the survey is still in its early stages and the longitudinal results will not be available for another 10 years. Selected Health Care Professionals: Conclusion The retention of allied health care professionals in rural and northern areas is crucial to the quality of health care for rural Canadians. Nonetheless, there is still little i known about selected health care professionals working in rural and northern areas of I 35 Canada. Appendix C contains a summary of the findings from the literature review. The table depicts the factors that were identified as influential in recruitment and/or retention for physicians, nurses, and selected health care professionals. However, these findings need to be replicated and elaborated. Recruiting health care professionals, who appreciate rural work, who are satisfied working in rural communities, and who will continue working in rural and northern areas is essential to effective health human resources planning and to the quality of health care (Pong & Russell, 2003). The level of influence that specific factors, such as training, personal background, and professional preferences, have on the decisions to choose and remain working in rural and northern practice needs further exploration. Summary Currently, there are few studies exploring the long-term, rural and northern health human resource workforce in Canada. The most prominent finding is the relationship between rural background and choosing rural practice. Having spouses, family, and friends in rural were also highlighted throughout the review. Community satisfaction and integration, along with social supports were also recurrent influences. Interest in rural living, professional autonomy, and variety at work were identified as motivations in several areas of the review. However, the influence of rural exposure during health care education was inconsistent throughout the review. The majority of the research on rural suitability pertains to rural medicine and students' perception of rural practice. There is little research specific to nurses and other health care professionals that explore the motivations for choosing rural training, coming and staying in rural northern regions. There are even fewer studies done that explicitly 36 look at personal characteristics and experiences of health care professionals in rural and northern areas. Identifying the personal characteristics and experiences shared by selected health care professionals who have worked in rural and northern Canada long-term will help with the appropriate selection of students for health sciences programs, lend administrators and policy makers insight into the recruitment process, and inform retention strategies. 37 Chapter 3: Methodology In order to explore the personal characteristics and experiences shared by selected health care professionals who have worked in northern B.C. long-term, the researcher engaged in a series of interviews across the region. The interviews targeted health care professionals who had already lived and worked in northern B.C. long-term. The interviews included questions about the reasons for choosing rural training, as well as motivations for coming and staying in the region. This chapter identifies the research questions, how these questions were addressed, and the design used to meet the goals of this research. This chapter includes a description of the participants recruited for the study, as well as how the data was collected, and analyzed. The steps taken to validate the findings and deal with ethical concerns are also presented in this chapter. Lastly, the chapter describes a brief plan for the knowledge translation of this research. Objectives With the creation of new health sciences programs designed to serve northern B.C., student recruitment will focus not only on those who have the capacity to complete the programs, but also those who are likely to stay and practice in northern B.C. (Johnson et al., 2006). The primary objective of this thesis is to identify personal characteristics and experiences shared by selected health care professionals who have lived and worked in northern B.C. long-term, and who plan to continue working in the region. The major goal of this research is to identify personal characteristics and experiences of selected long-term health care professionals in northern B.C. to contribute to the development of a suitability component for future health education program selection criteria. Previous research suggests an influence of personal characteristics and experiences on the decision 38 to become a rural physician or nurse in Canada, and this study extends that research by capturing the perspective of selected health care professionals who have already stayed in a northern and/or rural community long-term. The current research project examines the factors and experiences that these health professionals identify as influential in their choice to pursue rural training, initiate rural practice, and remain in rural practice. The results of this research can guide the future development of an assessment tool for the recruitment of health care professionals and health sciences students in rural and northern B.C. The UNBC Northern Medical Program currently uses the Rural Suitability Scale in their application process, and follows the progress and practice settings of their graduates. The findings from this study not only augment the UNBC Northern Medical Program admission committee's understanding of rural and northern suitability, but also that of the Nursing Program and other health care education programs where rural and northern suitability is considered. The findings of this research can inform health sciences student selection, aid in the future creation of a rural and northern suitability assessment tool, and provide evidence that can inform recruitment and retention strategies. Research Questions This study identifies characteristics and experiences shared by selected long-term health care professionals to inform the future development of an assessment tool for the recruitment of health care professionals and health sciences students in rural and northern B.C. The proposed study will ask the following research questions: 1. What factors are important to selected long-term health care professionals in northern B.C. when choosing rural training? 39 To answer this research question, selected health professionals who have lived and worked in the northern B.C. for more than four years and who plan to continue working in the region were recruited for participation in the study. To answer this research question, interview participants were asked to identify what factors influenced their decision to choose rural education (if they chose rural education), such as rural practicum or curriculum. 2. What factors influenced professionals' decision to choose northern B.C. as a work destination and stay long-term as health care professionals in northern B. C. ? To answer this research question, interview participants were asked to identify what factors influenced their decision to come and stay in northern B.C. long-term and discuss the importance of each factor identified. 3. What common personal characteristics and experiences are shared by health care professionals who have worked in northern B.C. long-term? The participants were asked to identify what personal characteristics and experiences have facilitated their decision to stay in the region and to be become long-term health care professionals in northern B.C. Design A qualitative descriptive design (Krippendorff, 1980) was used to meet the project objectives. The data collection was based on semi-structured interviews with 26 selected health care professionals who had lived and worked long term in northern B.C. The interviews were used to explore the personal factors that influence retention, asking longterm health care professionals to describe their personal characteristics and experiences in relation to the duration of their practice in northern B.C. The interviews were also used to analyze the different influences that motivated them to choose northern B.C. as a work destination. Data Collection The data collection consisted of a series of interviews with a variety of selected health care professionals from northern B.C. as defined by the Northern Health region (Bowering & Medd, 2004). The recruitment of participants for this study started with a convenience sample from the researcher's past work and experience in the area. The convenience sample was emailed a brief introduction to the research and a copy of the information sheet (see Appendix F). The information sheet included a short biography that described the researcher's northern B.C. upbringing and a brief explanation of how this research aimed to benefit the region's recruitment and retention initiatives. The later participants were then recruited using the snowball technique (Creswell, 2005). Potential participants who volunteered to be interviewed were entered into a temporary database and telephoned for an initial consultation to determine interview eligibility (see Appendix D). The volunteers were asked to identify the region within northern B.C. in which they live, how long they have worked as a health care professional in northern B.C., and where they planned to work in the future. Only volunteers who had worked in the region for more than four years and who planned to continue working in northern B.C. were asked to participate. Efforts were made to recruit approximately 5 volunteers per Health Service Delivery Area^HSDA) to participate in a telephone interview. The initial consultation ensured that a variety of different types of health care professionals were recruited to participate in the interviews. 1 The Northern Health region is divided into 3 distinct Health Service Delivery Areas: Northwest, Northern Interior and Northeast (See Appendix A) 41 The interview questions were pre-tested in 3 pilot interviews with health care professionals working at UNBC. Each interview question was evaluated during the pilot study. Questions that the participants indicated as difficult to understand or inappropriate were revised (Hegney et. al., 2002). The pilot study ran from November 15th through to December 1st, 2007. The interviews were completed between December 1, 2007 and February 14th, 2008. Before each interview, the researcher explained the research study objectives using an information sheet again, and read an informed consent form with the participant (see Appendix F). No incentive was offered to complete the interview. Once the participants had given informed consent and indicated whether they would like a copy of the interview transcripts, the researcher began the interviews. The semi-structured interviews included open-ended questions and were recorded on audiotape. A protocol for the semi-structured interviews can be found in Appendix E. The audiotapes, transcripts and temporary screening database will be destroyed by November 15th, 2014. Participants An overwhelming positive response to the research allowed for a larger sample than what had originally been planned with a total of 26. Six speech-language pathologists (27%), 4 clinical psychologists (15%), 4 occupational therapists (15%), 8 social workers (31%), and 4 physiotherapists (15%) were eligible and recruited to participate in the study, for a total of 26 participants. This included 7 (27%) participants living in the Northwest Health Service Delivery Area, 13 (50%) participants living in the Northern Interior Health Service Delivery Area, and 6 (23%) participants living in the Northeast Health Service Delivery Area. This sample was representative of the population with reference to Health Service Delivery Area population estimates by B.C. Stats (2008), which suggest approximately 26.5% of northern British Columbia's population reside in the Northwest, 50% live in the Northern Interior, and 23.5% live in the Northeast. Eleven (42%) participants were from the regional center of northern B.C., the one community that has a population of more than 50,000, and many of these professionals provided regional services to smaller surrounding communities. Data Analysis The interviews were transcribed verbatim using Express Scribe software and a thematic content analysis using a qualitative descriptive approach was carried out to identify any common phrases or comments that pertain to personal experiences, characteristics, and the decision to begin or stay working in northern B.C. (Patton, 2002). This process was carried out by Candice Manahan, under the supervision of Dr. Cindy Hardy. The interviews were analyzed by hand and a computer program was not needed. Transcribing the majority of the interviews personally as they were completed allowed the researcher to review the data, begin the constant comparative method of analysis, get familiar with the core consistencies, and elaborate on those consistencies in the subsequent interviews. Interviews were used to clarify, expand, and extend themes found in the literature review and the preceding interviews. Validating the Findings Processes to ensure qualitative findings were trustworthy, fitting, and auditable were undertaken, including expert audit. After saturation was reached, a process of member-checking was used for validation. Interpretations of the data were presented in a Powerpoint presentation to all of the interview participants via email (Creswell, 2005). 43 Each one of the participants was asked to assess the interpretations of the data and give feedback. The interpretations and themes were further validated by an external audit, where Dr. Karen Dyck, a rural clinical psychologist and researcher from outside of the project, was asked to review and report back in writing on the analysis and findings (Creswell, 2005). Dr. Dyck was provided with 8 of the original transcripts without any identifying factors to keep the participants' identity anonymous. Dr. Dyck was then provided with an initial draft of the thesis and asked to give feedback in writing on the validity of the interpretations. Dr. Dyck agreed the findings were grounded in the data and the conceptual model reflected what the participants reported (Creswell, 2005). Lastly, the findings were compared to the previous literature for validation and understanding of the themes. Ethical Concerns Ethical approval for this study was sought and received from the University of Northern British Columbia (See Appendix G). There were specific ethical concerns in this project because of the small sample size and the limited number of people occupying the selected health care professions in northern B.C. Therefore, special effort was given to ensure anonymity when reporting findings. Community names were not identified and only the Health Service Delivery Areas were used to describe geographic distribution. Most quotes do not name specific health care professions and any other identifying factors have been omitted to guarantee confidentiality for participants. Knowledge Translation The preliminary findings were presented to a number of rural health researchers, students, and health care professionals at the B.C. Rural and Remote Health Network Conference on May 14 ,2008. The researcher will undertake a further process of knowledge dissemination through the publication of the study results, by presenting at conferences, including the Canadian Rural Health Research Society Annual Conference. A summary of findings will be sent to Canadian education programs recruiting students for northern careers. Findings will also be shared with other rural and/or northern Canadian organizations that have had difficulty recruiting and retaining health care professionals. 45 Chapter 4: Results The purpose of this study was to identify personal characteristics and experiences shared by long-term health care professionals in northern B.C. The study explored influences in choosing rural practice, coming and staying in northern B.C., as well as personal characteristics and experiences that help make health care professionals suitable for long-term practice in northern B.C. The results of this study have been organized into five sections, similar to that of the interview structure. The first section describes the participants' demographics. The second section describes the discussions around choosing rural training. The third section explores the factors influencing the participants' decision to choose northern B.C. as a work destination and the fourth section explains the factors participants identified as reasons for staying in the region. The final section discusses the personal characteristics and experiences that participants named when describing why they thought they fit in as long-term health care professionals in northern B.C. There were very few differences in the comments made by members of the different health care professions. When differences between professions were noticed, they are mentioned throughout the results section. There were not any differences found between HSDAs. The quotes used throughout are only identified by HSDA to ensure participants' anonymity. Demographics Geographic Location Only 5 (19%) of the 26 participants in the study identified themselves as being originally from northern B.C. Four (15%) participants were from overseas, 6 (23%) from Eastern Canada, 2 (8%) from Manitoba, 1 (4%) from the Yukon, 4 (16%) from Alberta, 46 and 4 (12%) from Southern British Columbia (see Table 1). Eight (31%) participants described their original hometown to have a population of less than 10,000, 6 (23%) participants described their hometown as having a population between 10,000 and 100,000 and 12 (46%) described their hometown as having a population larger than 100,000. The participants spent various amounts of time living in northern B.C. and only a few of them had moved around northern B.C. to various communities. Most of the participants (69%) had spent more than 2/3 of their career in northern B.C. However, only 6 (23%) had spent more than 2/3 of their life in this region. Every participant planned to remain working in northern B.C., but 2 (8%) of the participants were married to police officers and did not think they would be able to remain working in the region due to spouses' transfers to different regions. Table 1 Participant Table: Summary of Participant Demographic, Personal, and Educational Background Factors Factor N Approximate % Current Occupation: Physiotherapist Psychologist Occupational Therapist Speech Language Pathologist Social Worker Current Community: 4 4 4 6 8 15 15 15 23 31 Northwest Health Service Delivery Area Northern Interior Health Service Delivery Area Northeast Health Service Delivery Area Region of Origin: 7 13 6 27 50 23 Northern British Columbia Southern British Columbia 5 4 19 15 47 Alberta Yukon Saskatchewan Manitoba Eastern Canada Overseas Hometown Size: 4 1 0 2 2 4 14 4 0 8 8 23 Population less than 10,000 Population between 10,000 and 100,000 Population larger than 100,000 Spent more than 2/3 of career in northern BC: 8 6 12 31 23 46 Yes No Spent more than 2/3 of life in northern BC: 18 8 69 31 Yes No Married or living in common-law relationship: 6 20 23 77 Yes No Spouse from Canada: 20 6 77 23 Yes No Have children: 18 2 90 10 Yes No Live within 50 km of parents: 21 5 81 19 Yes No If married, live within 50 km of spouses parents: 3 23 12 88 Yes No Have extended family living in northern BC: 4 16 20 80 Yes No 11 15 42 58 48 Health care education in northern BC: Yes No Practical training in a rural or northern area: 7 19 27 73 Yes No Education included rural or northern specific curriculum: 10 16 38 62 Yes No 7 19 27 73 Spousal and Family Factors Twenty (77%) participants were married or living in common-law relationships at the time of the interview. Approximately half of the married participants stated that their spouse was originally from northern B.C. Most of the other spouses were from various communities across Canada and only 2 (10%) of the spouses were from overseas. Nearly every participant who was married reported that their spouse was satisfied with their current community and had career opportunities in northern B.C. Twenty-one (81%) participants identified that they had children and almost all of them claimed that their children were satisfied with their current community. Most of these participants also discussed the opportunities available for their children in northern B.C., including recreation and education. If you have school aged children or young children here, it is a wonderful opportunity to raise your kids. There is a lot of sports and recreation. (Northern Interior) Most of the participants lived more than 500 kilometers from their parents, and from their spouses' parents. Many of the participants had parents and spouses' parents 49 living in southern British Columbia, but quite a few of them had their parents living in other parts of Canada. Only 3 (11.5%) of the participants had parents living within 50 kilometers of them at the time of the interview. Meanwhile, 4 (20%) of the married participants lived within 50 kilometers of their spouses' parents at the time of the interview. Eleven (42%) of the participants had other extended family members living somewhere in northern B.C. Almost all of the participants in the study claimed to have no friends living in the region when they arrived, but presently had many friends in their community. Summary Overall, the participants were from various regions and countries, although most of them were originally from Canada and almost half of the participants had a hometown with a population of more than 100,000. Most participants were married and their spouses were satisfied in their current community. Similarly, the majority of participants had children, who were also happy with living in northern B.C. The largest part of the sample did not live close to their parents or spouses' parents, but many had family in the region. Generally, the participants had spent most of their career in the region and started working in northern B.C. shortly after graduating from their health care education program. Rural Training Seven (27%) of the participants did their health care education in northern B.C. A few of the social workers felt that the reason they chose social work as a profession was because the program was available in northern B.C. and they already lived in the region. 50 / was already living in the region and basically I chose a program that I could complete in northern B. C. that I wouldn 't have to relocate to do. So, my choice of i profession is based on what was offered, not necessarily based on what I wanted i to do. (Northern Interior) Other participants did their health care education in various other regions of Canada and overseas. Ten participants (38%) did their practical training (such as their clinical placement, practicum, or internship) in a rural or northern area, but most of them did not feel the placement influenced their decision to work in northern B.C. Seven participants (27%) learned about rural and northern health issues during their health care education, but only 1 (17%) participant felt that this had an influence on choosing northern British Columbia as a work destination. All of the participants who did their practical training and/or learned about rural and northern health issues during their health education had already decided they were probably going to work in a rural or northern setting before they had the opportunity to take part in the rural education component. Nonetheless, the participants who completed rural or northern training suggested that the training helped to prepare them for their current employment. Practicum in rural areas gave me an idea of what I needed to be successful in rural areas. It really helped me to know what I needed to ask from my employer to be successful before I even started. (Northeast) Overall, having training programs in northern B.C. appears to have a positive impact on retention, as a few of the professionals based their choice of profession on the programs available in their region. Although rural curriculum and practicum did not generally influence participants' decision to practice rurally, it did prepare graduates for i 51 their future employment and the recruitment process. Table 1 summarizes the demographics and the personal background, including educational background, of the health care professionals who participated in the study. Recruitment The purpose of this study is to inform future recruitment and selection. Therefore, the researcher asked participants to identify the factors that were important in their decision to choose northern B.C. as a work destination. The findings were organized into four categories: personal background, professional factors, individual factors, and community factors. Personal Background and Family Factors More than a few participants mentioned past, positive experiences in rural and/or northern communities when discussing their reasons for choosing northern British Columbia as a work destination. A similar number of those interviewed suggested that growing up in a rural or northern community was significant in their decision to choose the region. Growing up in the Yukon and having my first degree there I... some people who had gone to UVIC who left with their degrees from UVIC went to Grouse Mountain and worked on a ski hill for $10 an hour because that is all they could do. And I went north back home to Whitehorse and my first job was from the government, paying close to $30 an hour as a corrections officer. So, certainly from a very early age, I understood that the north was ripe with opportunity: advancement opportunity, promotion opportunity, travel outside for training opportunity, and all those things. (Northern Interior) A smaller number of people suggested that the fact that their spouse was originally from a rural or northern community urged them to choose this area. A few more mentioned that having family members in the region had a positive impact on their decision to start working in northern B.C. However, a very small number of participants mentioned getting away from their family as one of their reasons for coming to this region. / have joked and said that I have put a mountain range between me and my parents (laugh), but I wasn 't escaping them. Rather, I was exerting my independence. (Northwest) A small number of health care professionals noted that wanting to raise their children in a rural or northern community was a prominent factor in the decision to work in northern B.C. My husband and I are trying to have a baby and I want to raise my child in that type of community. Where he knows his neighbors, he knows how to get to the mall, he knows all of those things that I did growing up. I could walk to the pool by myself and I didn 't need a bus and I didn 't need someone to drive me. I would ride my bike or walk. (Northwest) Personal background and family factors influence recruitment, but many participants identified professional factors as the most influential. Professional Factors Financial incentives are currently one of British Columbia's main recruitment techniques (Ministry of Health, 2006). However, only a couple of the participants named financial incentives as important in their decision to come and work in northern B.C. 53 Most participants identified potential for career advancement and the need for health care professionals in the area as poignant in their decision to work in northern B.C. / think the most important was that I would be going to a community that needed my services... So that I would have, I mean, opportunities to be of assistance to people who needed services, but that I would be able to establish a private practice that would have meaning for me. (Northern Interior) More than a few of the participants were influenced by their spouse's career opportunities in the region. My wife is very smitten with the place because, as I said, she is an artist. (Northwest) Several participants also described how the friendliness and helpfulness of employers and recruiters were very influential in their decisions. The correspondence I had with the hospital in this area, the hospital that employed me, was extremely encouraging. They were very helpful and helped me find somewhere to live. They were delighted that I was coming. They sounded like extremely friendly people. The initial contact that I had with the people here was very positive. (Northeast) A few participants described the supportive environment and escaping a competitive environment as a reason for coming to northern B.C. In (an urban center), there is quite a competition thing that goes on because of course, it is a larger center, people are very territorial about their clients, their contracts and stuff. Here, I mean, the response I got when I asked questions (about moving here) was that nobody was threatened. Everyone was eager for me 54 to come and offered all kinds of information and assistance that I would have never received. (Northern Interior) Others mentioned the opportunities promised by employers to provide continuing education as a motivating factor. The opportunity to set up private practice and/or change their practice environment to something more community-based were also factors named as having influence on recruitment, especially for the psychologists. The model of delivery and the opportunity to work as part of an inter-professional team was also considered to have an influence on several of the participants' decision to choose northern B.C. Another thing that was really important to me when I was deciding to work up here was that it is very important for me to enter a team. Before when I worked in Ontario, I worked in an environment very similar to this, but it was a private practice. The practice itself was quite isolated and I didn 't have a team around me. And that experience was very...well, we have a really good team here and we have a couple of people who have been here for a very long time. And they are the foundation of the team. When I was looking for a job. ...that made this position more attractive to me. (Northeast) A small number of health care professionals also suggested that the opportunity to teach at a college or university had a positive influence on their decision to choose northern B.C. A few of the participants claimed the variety and challenges found in rural and northern communities triggered their decision to work in the region. However, a small number of participants, all rehabilitation professionals, claimed the chance to work in pediatrics triggered their decision to come to the region. 55 / wanted to move into the pediatric field. I knew I was going to have to stay in Ontario or move to British Columbia where there was a good network of children's therapies in both provinces. (Northern Interior) In summary, professional factors not related to financial incentives had a major impact on recruitment. Opportunities for advancement and to try different aspects of the job were identified as influential. Participants identified a number of personal preferences for particular professional factors that affected their decision to practice in northern B.C. Individual Factors Several individual factors and personal preferences were discussed when participants were asked what factors influenced them to choose northern B.C. as a work destination. The need for an adventure brought several of the participants to northern B.C. It wasn't the money that drove me. It was the adventure! (Northeast) Another one of the main attractions to northern B.C. was the beauty of the region and the accessibility to the wilderness. The reason that we moved to northern B.C. was to experience Canada and everything that is Canadian. I wanted to see the rivers, the trees; the geography of the place. I wanted to paddle a canoe, spend time in a log cabin on the lake and to have a Canadian experience. I wanted to see guys hunting andfishing\ (Northern Interior) Many participants also discussed the activities and recreation available in rural and northern communities, including mountain biking, gardening, hiking, and skiing. / wanted to work in the mountains. I wanted to be in a place where I could hike and ski. And I saw (northern B.C. community) on a calendar; there was a mountain and there was a lake. I thought, 'I could live there!' (Northwest) A few of the participants also mentioned that their spouse's love for the outdoors had an impact on their recruitment. Some participants discussed other activities and clubs they favored that were available in northern B.C. For example, a few of the participants enjoyed photography clubs, while others appreciated canine agility clubs. / was impressed by the fact that (this community), given how small it is, has a symphony, has live theatre, all the sports and has... well, my dogs are at the point of competing in agility and the agility clubs that are here are huge... my dogs are like my kids! (Northern Interior) Participants suggested that appreciating the activities available to them in their communities were important to their decision to practice in northern B.C. Community Factors The friendliness of the community and the people in rural and northern communities was a determining factor for several health care professionals evaluating the choice to live in northern B.C. Some of the participants also discussed the informal attitudes and casual way of life found in rural and northern communities. One of the major themes when talking about choosing northern B.C. was that it was a lifestyle choice. We were ready for a change... that lifestyle. It was a lifestyle choice more than anything. We thought that well, we were starting out together and we wanted to 57 just sort of change some of our values and priorities around how we spend our money and those things. (Northwest) Several participants highlighted the less expensive housing, the time saved by not commuting and the slower pace they found living in northern B.C. rather than in a metropolitan area. This allowed them to spend more time with their family, go on vacations and participate in recreational activities more. / think the other advantage to this community as a whole is of course the cost of living is very different. So, it allows you to.... If you have got a passion in life, like if you were somebody who-1 don't know- acquired objects of art... you would have way more money available to do that if you were living up here, than if you were living in the Lower Mainland. So, there are a lot more ways up here to kind of nurture those kinds of passions that keep you professional life alive, as well. (Northern Interior) Several participants discussed the "slow pace" of rural living or the "relaxed" lifestyle as an attraction to northern B.C. They discussed escaping the long commute to work, the traffic jams, and the time lost between work and home. A few of the participants discussed escaping the crowds and the busy feel of larger centers. A smaller number of participants also discussed getting away from pollution and embracing a healthier lifestyle as part of their decision to move to northern B.C. Well, I had lived in Toronto for years and really couldn 't take the grid lock anymore. The highways, the pace of it, the pollution. And it is even worse now! So (part of the reason for moving) up to B.C. was that continuing there didn't really appeal to me. I like the slower pace here... (Northeast) For many it was a lifestyle choice that brought them to northern B.C. Several participants identified getting away from the busy-lifestyle found in urban environments as one of the main reasons that they decided to practice in northern B.C. Summary Participants identified personal background, professional, individual, and community factors that were important in their decision to choose northern B.C. as a work destination. Generally, participants identified past positive experiences and rural background as influencing their decision to practice in northern B.C. A few named their spouses origin, having family in the region, and wanting to raise children in the area as impacting their decision to come to northern B.C., while others suggested getting away from their family as their reason. Participants named the need for health care professionals, career advancement opportunities, welcoming employers, peer support, as well as promises of continuing education and interprofessional teamwork as key to their decision to come to northern B.C. Personal preferences for variety, challenges, and trying new aspects of the job such as teaching also impacted their decision. The sample identified several individual factors and personal preferences when explaining what influenced them to come to northern B.C. The need for adventure, the love of the wilderness, and outdoor recreation were all identified. In addition, community factors such as friendliness of the people, low realestate prices, and slow-pace of living influenced participants' decision to come to northern B.C. Many of these factors were also identified as influential in retention. Retention A handful of participants had come to work in northern B.C. with the idea that they would get a few years experience and move on. However, every participant had eventually decided to stay in the region long-term. The purpose of this study is to inform future recruitment and selection decisions by identifying those factors that influence retention of selected health care professionals in northern B.C. Therefore, interview participants were asked to identify what factors have influenced their decision to stay in northern B.C. long-term. The findings were organized into four categories: personal background, professional factors, individual factors and community factors. Personal Background and Family Factors A few people suggested that past, positive experiences in rural and northern experiences kept them in the area. The minority of participants claimed that growing up in a rural or northern community had an influence on their decision to stay in the region. Some of the participants discussed how similarities between where they grew up and their current community made them feel more comfortable and consequently were factors in their retention. For me, it feels like where I used to live in northern Manitoba. It has sort of a similar weather pattern, like the days in summer are really, really long and sometimes the sun just hits the horizon and comes back again. For me, it brings back my childhood... (Northwest) Almost half of the participants named staying close to family who are living in northern B.C. as a reason for staying, as many of the health care professionals now have their own children in the region. Wanting to raise children in a rural or northern community became a strong motivation for people to remain. Many participants discussed wanting to stay so that their children could finish school in one community. Participants also talked about the need to stay in the community to be close to their grandchildren. Well, number one is my family. My daughters are here and my grandchildren are here. And we are pretty close grandparents, my wife and I, so that is one of the main motivations to stay here now. (Northern Interior) However, more than a few participants claimed that finding a spouse who was already living in the region was important in their decision to make northern B.C. their home. A number of participants also identified their spouse's appreciation for rural or northern living, as well as their spouse's rural upbringing as influential on their decision to stay. You would not find my husband in Vancouver. You wouldn't even find my husband in Kamloops or Kelowna. It just does not suit him. He has developed this Northern identity. (Northern Interior) Personal background and family factors were identified as influential in the decision to stay long-term in northern B.C. However, it seems personal background is less important than family and spousal factors. Professional Factors One of the most common retention factors was the need for health care professional services in northern B.C. and the career opportunities for both the health care professional and the spouse. Many participants discussed the opportunity to become a sole practitioner and the chance to grow within their career. Several participants 61 discussed their employer giving them managerial support, training and continuing education opportunities as influential in their choice to remain in northern B.C. There were just a lot of opportunities for training. So, that was a big, big benefit for me; a reason for me to stay. Um... That I didn 'tfeel like a lone ranger out here without a lot of support for learning the position. I was able to do lots of courses in Vancouver and in the United States. I did some mentorship stuff with one of the occupational therapists in Kitimat and did a couple of courses in Prince George. In my first couple of years, I got a lot of support and a lot of training. That definitely gave me a strong foundation. (Northwest) Almost half of the participants mentioned the importance of peer support in their decision to stay in northern B.C. A few of the participants discussed how the limited resources and a small number of professionals working in the region often increased the need to become familiar with other people working in the same line of work. Therefore, some of the participants felt the professionals support systems were often smaller, but tighter than the supports found in metropolitan centers. Several participants described the community-based approach they took at their job and highlighted how professionals would come together across disciplines for the well-being of the community. Many professionals felt a professional commitment to their community. / think I contribute a lot to my community. I have been here for so many years that I know the population and its needs- more so than a new grad or someone who has come from elsewhere. So that is good. It is a good return. I can contribute more. (Northeast) 62 More than half of the participants identified job satisfaction as one of their main motivators for remaining in northern B.C. Job security and having a full-time, permanent position was identified repeatedly as motivation to stay in northern B.C. Several participants discussed their preference for variety in their work and the opportunity to challenge their skills. I do love my job! It is a fabulous job! It is changing everyday... It is so diversified! (Northwest) Numerous participants discussed the professional autonomy found in rural and northern settings. More than a few of the participants discussed the opportunities to try new approaches and pilot projects in northern B.C. Consequently, they had become more committed to their work in the region. There are some things I still want to achieve here. We keep growing and we keep designing new programs and we keep expanding. There is still so much work to be done. It is not as if we can just say, 'Oh well! We will just sit back and let things run now'. So, there are always fresh challenges and I like that. (Northern Interior) Nearly half of the participants mentioned their spouse's career opportunities when explaining what kept them in the area. Although financial incentives were not mentioned at all during the discussions regarding retention, some of the participants discussed the job stability and full-time permanent employment they had in northern B.C. as significant in their decision to remain. With young children, I really wanted a dental plan and a medical plan. I really wanted security, too. And the 'someday retiring' is suddenly not that far away. So, 63 staying here... well part of it is that I have a really good job...I am feeling pretty secure here and I would be pretty reluctant to move anywhere else. (Northeast) Individual Factors Similar to professional preferences, many participants named personal preferences and individual factors as motivation to stay in northern B.C. Several participants discussed their love of adventure as a reason for staying in northern B.C. The beauty of the region, as well as the accessibility to the wilderness was also a theme. Many participants talked about the outdoor activities and recreation available to them in their community when they explained why they continued to live in northern B.C. Hunting, fishing, snowmobiling, hiking, mountain biking, and skiing were all mentioned. More than a few participants also emphasized the recreational opportunities that their spouse had in the region. He loves to fish. He is an avid fly fisherman. So, his hobbies are here! (Northwest) Several participants discussed other activities, such as participating in their community theater, choir, symphony, and arts. Their preference for recreational activities found in the region, as well as for the weather patterns also came up. / have been born with a love for the winter. It pretty much could be winter all of the time for me. All year round and I would be happy as a clown. While everyone is celebrating the spring, I am usually grieving the loss of winter every year. I have always wanted to be in a place that had a good winter. (Northwest) "Close relationships" emerged as a general theme in retention, as many participants described how they had found closer friendships in their northern community which had influenced them to remain in the area. We lead a simpler life. Again, that is not to slam, but it is to say that a gathering might happen in someone's home around the hearth of their fireplace, which is different than, "O.K. let's meet uptown after work at Moxie's or the G-Club and we'll have some martinis. It is just a different vibe. It is quieter, simpler, let's get together, huddle around and get through winter. Let's draw our strength and joy from our relationships and friendships instead of it being necessarily from things and concerts...(Northern Interior) More than a few health care professionals who were interviewed stated that they identified as a "Northerner" and they simply felt northern B.C. is their home. / am a Northern girl! I don't like the Lower Mainland. I love the people here. I like the weather. I enjoy the resourcefulness of people. I enjoy the activities that we can do in the winter and in the summer. And I like our location and the size of the community. I am a Northern girl! (Northwest) Community Factors Identifying with the community and appreciating the current community were both recognized as motivation to stay in northern B.C. Many participants mentioned the friendliness of the people in their community as a major indicator in their decision to stay. Participants suggested that northern people are friendly, welcoming, and make you feel comfortable. More than a few participants discussed the appreciation of rural or northern lifestyle as a key in their decision to continue working in northern B.C. Health 65 care professionals explained the "slow pace" and "relaxed" lifestyle helped them to stay in their current community. One of the major themes was how the affordability of living in northern B.C. allowed for more time to spend with family. It is much more affordable with the housing especially. My family of three, we can get by on one income. And I can't see doing that if we were living in Vancouver or on the Island. I can't see doing that. My wife would have to get a full-time job. Our lifestyle would change. Our quality of life would be different. So, we stay because we like the quality of life in terms of affordability. (Northwest) Several participants pointed out that they had a better quality of life working in northern B.C. because they had more money to do the things that they liked to do, like going on vacation. In terms of the overall cost of living around, you know, owning a home, property taxes, and the vehicles and trips you can take. I mean, we have friends that live in Vancouver and their trip is in their house... that is what their mortgage allows them. Whereas my family and I take a number of trips a year which are ranging from mini ski vacations to, you know... In one month, I am taking a cruise in the Caribbean. So, I don't want to negate the fact that I am living in a wonderful house, that I just built... I enjoy a nice quality of life that comes from having two incomes and I am not sure that my counterpart in Vancouver would be enjoying the same. That is certainly some motivation around the job... (Northern Interior) One of the major themes relating to retention was community satisfaction. Several interviews highlighted the importance of people coming together for the health of the community, adding to the "sense of community" and community satisfaction. Various interviews highlighted the individual commitment and/or vested interest in the community as a factor in retention. Obviously my husband is a big factor and I can not deny that. However, you do have to think on your own two feet and I think that this is my home now, too. And that is important to me. And even things like the dam issue and things like that... I have a vested interest in the area here. That means a lot me, too. (Northeast) The desire to know the people living in their community was also highlighted as having a positive impact on retention. When I walk down Main Street, I know everyone. People talk. It is a feeling of community that I would not get in a big city. That is a reason that I have stayed. (Northwest) Numerous health care professionals discussed the safety and comfort associated with knowing the people in their community, and many people talked about how much they appreciated the familiarity associated with rural and northern communities. It is a different closeness. It is friendliness when you walk down the street. It is recognizing people in (the store) even though you have never met them, but you have seen them out and about few times. It is going into church and recognizing the congregation. It is a warmth I think that maybe comes from bonding in the north. (Northern Interior) People discussed the importance of social support networks, and a major theme was the feeling of belonging within a community when discussing the reasons they have stayed working in the community. 67 / have a network of friends here that I have developed over the years. I would feel a sense of loss of I moved away from them because I would feel like I would have to start from scratch. I like that feeling of knowing people when I go out to the grocery store. I like running into people that I know. It makes you feel like you belong here. Those factors would discourage me from leaving. (Northern Interior) Participants suggested that getting involved in what their community had to offer was a retention factor. They also discussed how their families had gotten involved in the activities offered in their community. There is a really strong arts community here and my husband is an artist. So, he is connected with the arts and there really is a strong music community. That is important to our kids; they are really involved in music. And there are tonnes of outdoors stuff. So, if you wanted you could be on the cross-country ski team or downhill ski team. There is no end to the recreational pursuits or sports... (Northwest) A number of health care professionals suggested participating in their arts community was more accessible in comparison to metropolitan communities where it can be more competitive. We have always had the orchestra and the (theater); that has been very important to me. And the ability to take part in it! You could act, or you could direct, or you could produce. You can be part of any community that you want to be part of here. It really binds you to the community! (Northern Interior) A small number of participants discussed the ability to make connections with their patients and really see a difference they make in the community. 68 / think we are able to have a really good connection with our clients. I think we are able to make a difference and at times, it is a noticeable, visible difference. So, there is more gratification, an instant reward. I am not sure if you see that in a larger center. (Northern Interior) Summary In conclusion, participants identified several aspects of the community, the job, and of the region itself when describing why they had decided to remain working in northern B.C. Similar to those factors that were identified as influential in recruiting these professionals, personal background, professional factors, individual factors, and community factors all had varying levels of impact on their decision to eventually stay in northern B.C. Although past, positive experiences in northern communities and rural upbringing were identified by some participants as influential in their decision to stay, the larger motivation appears to be to stay close to family (children and grandchildren) and spouses living in the region. Retention was also impacted by several professional factors, such as the need for health care professionals, career advancement opportunities, professional autonomy, peer and managerial support, and continuing education. Job satisfaction and professional factors that influenced job satisfaction were the most important professional factors influencing retention. A commitment to the community and the community-based work were also highlighted. Community satisfaction, getting involved in the community, appreciating the activities the community has to offer, and the quality of life found in northern B.C. were all identified as factors involved in their decision to stay in northern B.C. The sense of belonging to a community, familiarity, and knowing the people in the community that develop over time were also identified as retention factors. Similar to the reasons that these participants came to northern B.C., adventure, a love of the wilderness, and outdoor recreation were all named as factors influencing them to stay. Most participants did not have friends living in the region when they arrived, but many developed close friendships over time, which influenced them to stay long-term. Others developed a "Northerner" identity over time, which impacted their decision to stay. These findings introduced the personal characteristics and experiences shared by long-term health care professional in northern B.C. Characteristics The major goal of the current study was to identify personal characteristics and experiences shared by long-term health care professionals in northern B.C. This section identifies the personal characteristics that participants perceive as important to the longevity of their practice in northern B.C. This section is divided into four sub-sections: personal background and family factors, professional factors, individual factors, and community factors. Personal Background and Family Factors Most of the participants identified past, positive experiences in rural and northern communities when discussing what made them come and stay in northern B.C. longterm. Some of the interviewees suggested that growing up in a rural or northern community made people more suitable for working in northern B.C. A small number of those participants who grew up in northern B.C. identified rural or northern background as integral to working long term in the region. Some of these participants discussed how 70 their experience growing up in a rural or northern community helped them to relate to their patients and consequently helped them succeed as a health care professional in the north. / grew up in northern Alberta, a rural town. Actually I grew up on a farm, 20 minutes from our rural town. So, I am very familiar with struggles that people in the north have, right? Particularly when they are trying to access health care; you know, so I have that background of not having running water and using wood heating or an outhouse. I am able to pull all of that information and bring it forward to recognize the struggles that some of our patients endure. (Northern Interior) Among those participants who had extended family living in the region, several highlighted how much they valued living close to family. However, many of those living away from family discussed the ability to be independent and live away from family as key to remaining in the region. Some sort of independence. They must not want to live on their mother's doorstep or their twin sister's doorstep. They will have to have that little bit of adventurous spirit so that they are prepared to separate from family. (Northern Interior) Professional Factors A major theme was the need for health care professionals to be able to be independent and confident in their abilities at work. Several professionals described their appreciation for professional autonomy and the opportunities they had as a sole charge in northern B.C. Many participants discussed the need to be on your own and able to think on your feet in order to work as a health care professional long term in northern B.C. 71 / think I like a challenge. I think that if you like to work 8 to 4, you like routines, and you like a lot of support... I don't think it will work. I think you need to be able to work both independently and as part of a team, but you can't depend on someone else or other resources all of the time. You have to be able to think outside of the box. If you can't and you get high anxiety doing that, you will not like it here. (Northwest) Numerous participants suggested that their generalist perspective made them the kind of person who works in northern B.C. long term. Several participants described their flexibility in terms of appreciation for variety at work / think I am very flexible and I think that is a huge one right there. I welcome change and that is part of the flexibility. I actually embrace change and I think a lot of other people have difficulty with that. (Northwest) More than a few participants also described how much they enjoy their professional skills to be challenged on the job when they talked about what made them fit in as a health care professional in northern B.C. Well, professionally I am a generalist. I know a little about a lot of areas. I am competent in those areas, but not a specialist in any areas. We only have two [professionals doing this job] here. So, we have diverse clients and diverse issues. I like having that challenge of finding a way to deal with that. (Northeast) Most participants highlighted professional resourcefulness as pertinent to their ability to work long term in northern B.C. Most participants described the ability to be creative with what resources they had available to them as an instrumental characteristic in determining why they were able to work long term in northern B.C. 72 / mean look at how many communities that we have that do not have detoxification units and don't have this or that. So, you end up doing a lot of creative problem solving. So, I think to survive in the north, you have to be creative instead of relying on existing services. Sometimes you have to create services! (Northern Interior) Several participants also explained that they were flexible in their professional life and this helped them to become a long term health care professional in northern B.C. You have got to have flexibility and adaptability because it is not like practice in a large centre where you have numerous resources. You have to be very creative up here and I don't think all professionals are. (Northern Interior) Many professionals discussed the ability to work flexible hours, travel for work, and work within the community instead of in an office. Valuing the clients and the work you do above the sometimes-less-than-optimal working conditions was also emphasized. You have to see a value in what you are doing yourself. It doesn't matter what anyone else thinks. The value in yourself and put in as many hours as necessary and you have to do it on the road. And I imagine I like it on some level because I keep doing it (laugh)! (Northern Interior) More than a few professionals discussed the ability to create clear distinct boundaries with patients when working in rural and northern communities. You have to be able to balance your professional and your personal life by developing boundaries that may not make sense in an urban environment. (Northern Interior) 73 Several participants mentioned their ability to adjust their role within the community and keep their professional life and personal life separate were essential to working long term in the region, especially the psychologists and social workers. You always have to be mindful of the overlapping relationships here. Actually, that is the biggest aspect when you are working here. You are in afishbowl with all sorts of contacts with people that overlap. Your clients and children of clients. You have to have a mindset that is tolerant and aware of the role you are in at the time. As a professional, you have to be able to change your role. You have to have that adjustment and I do not find that difficult. Those are some of the things that help me fit in here. (Northeast) In summary, several personal characteristics related to professional preferences and abilities were identified as important to working in northern B.C. long-term. The preference for a generalist practice and challenges at work was shared amongst most participants. The ability to work independently, confidently and creatively, as well as being flexible and resourceful were also named by many participants when describing the personal characteristics that were important to working in northern B.C. long-term. Valuing northern people and recognizing dual relationships were also characteristics shared by participants in northern B.C. Individual Factors Valuing the quality of life offered to health care professionals in northern B.C. was stressed during the interviews as poignant in their capacity to be long-term health care professionals in the region. According to participants, the quality of life is not 74 necessarily better, just different in northern B.C. in comparison to other more metropolitan centers. The difference is all the other amenities that come with living here. I only have a 10 minute commute. I don't have to worry about traffic jams. I don't have to worry about all the pressures of a big city. I like the fact we are close to the outdoors. I like the fact that I can afford a house here. I like all those things that you can't get in larger urban centers. (Northern Interior) Participants suggested that they did not highly value the opportunities found only in metropolitan centers. They did not feel like they were missing out because they lived a far distance from a metropolitan center. Sure I can't go to the opera or to a play when I want to. And I can't do the shopping that I could do down south, but I am fine with what I have here. I don't feel that I am missing out on those things at all. (Northwest) More than a few of the participants also discussed how they did not enjoy crowds and they had an appreciation for wide-open spaces. / guess I sort of fit in the North because there is fewer people in the North and that gives me space. It gives me breathing space and I like that space. (Northwest) Many participants described their love of the region and the climate when explaining why they were the kind of person who enjoyed working in northern B.C. long term. What I like about the region is that there are so many lakes, rivers, forests, wildlife... and in the wintertime, if you learn to play in the snow, you can have lots of fun here. (Northern Interior) 75 Many participants described themselves as valuing their personal time more than work or money when they talked about why they were the kind of health care professional who works long term in northern B.C. / didn 't want to get caught up in ... or it is not really important to me, not to feel that I had to put in 40 hours of work a week, then traveling to and from. Just not having any time for myself and not having time to do anything. It is the quality of life that is huge for me. So, even though I was single and on my own, I didn't work full-time because I felt that having the extra day off to pursue learning was really more important to me. Part of that is the affordahility. You can live a simple; more affordable lifestyle that will allow you to do that. (Northwest) When asked about what makes them the kind of person who works long term as a health care professional in northern B.C., several participants emphasized that their need for status or prestige was not a priority. / guess that to some extent, people in the North are less materialistic when it comes to what they need to gather. And the whole sense of status is perhaps less important to me. So, the clothes I wear, the car I drive, what my house looks like. These are less important to me, while people that move away are maybe more status conscious. People have said that they are surprised that women are coming to our office in pants or not dressed to the nines. It is just less important... and wearing hiking boots around the office is fashionable clothes (laugh)! Those kinds of status things are less important to me. (Northwest) Many participants highlighted that they were "not materialistic" and enjoyed a more casual way of life. More than a few participants emphasized that they had a casual outlook on both life and dress! / used to work in downtown Calgary and all of the women's shoes matched their purses, you know (laugh)?! I call it cosmopolitan. And (our community) is much more laid back. So, if things are important to me, like my shoes matching my purse and no one else cares... I think it would just be incredibly frustrating if that was something that was really important to you. (Northern Interior) Another major theme was being adventurous. Health care professionals from various backgrounds stressed the importance of being adventurous when describing what makes them the kind of health care professional who works in the region long term. It was more of a sense of adventure that brought me to (a northern B.C. community) and I think that is something that you do see in a lot of people that live in rural and remote communities. They have a sense of adventure. They have a sense of who they are and they are comfortable with themselves and their surroundings. (Northern Interior) However, this was a stronger theme among individuals who were from eastern Canada and overseas. This group stressed their love for travel as key to being the kind of person who works as a health care professional long term in northern B.C. Many participants felt that their social availability and ability to make friends easily made them more likely to be a long term health care professional in northern B.C. Several participants emphasized the need to be open to new friendships and underlined the importance of a social support network in northern B.C. 77 (You need) an openness because in the winter time you can kind of get closed in. If you are open to new relationships and new friendships, you won't feel isolated. You know, because if you are not the kind of person who can go out and meet with people... yah the winters are going to be long (laugh)! You will be stuck in your house and it will be long! (Northeast) Overall, the results suggest that long-term health care professionals in northern B.C. value the quality of life available in the region. The appreciation of the wide-open spaces, the landscape, and the climate are all characteristic of the participants. In general, the participants valued personal time over money, were not interested in status or prestige, and enjoyed a casual way of life. The participants emphasized that being adventurous and sociable are characteristics that have impacted the longevity of their practice in northern B.C. communities. Community Factors When participants were asked what personal characteristics help them to "fit in" and live long term in northern B.C., almost every participant identified that they felt a commitment to their community. Most participants also discussed taking part in what their community had to offer and getting involved in community activities as a personal experience that has made them the kind of health care professional who appreciates working in northern B.C. long term. / think that the people that stay find their own way to get light... their own way to stay alive. It doesn't come from the restaurants and the services that are offered. It comes from having friends, from being part of the community, from taking part 78 in the activities that are natural that the community and surrounding areas can offer you. (Northwest) Several participants described their respect for diversity and understanding of cultural diversity as a personal characteristic that helped them to be the kind of person who stays long term in northern B.C. You need to have an understanding of cultural differences. There is a difference between what is accepted say in Prince Rupert, than what is accepted in Fort St John. There is a need to be cognizant of the community mores throughout the region. (Northern Interior) One of the underlying themes associated with being a long term health care professional in northern B.C. was the appreciation of being part of a community and a sense of belonging. / think you have to value the sense of community, value the sense of belonging. Umm... as opposed to other things you may find more of in the city. (Northern Interior) Quite a few participants discussed how much they enjoyed knowing the people in their community and appreciated seeing familiar faces. / like that small town community aspect that you can walk into a store and you know a lot ofpeople. I really like that feeling. (Northwest) Overall, being committed to the community, active in the community, and respectful of cultural diversity were all personal characteristics that were shared by most participants. The participants identified an appreciation for the sense of belonging and knowing people in the community as poignant to their ability to stay long-term in northern B.C. Summary The major goal of the current study was to identify personal characteristics and experienced shared by long-term health care professionals in northern B.C. This sample of health care professionals reported a number of personal characteristics germane to working long-term in northern B.C. Most participants identified some form of rural background or exposure as integral to working long-term in northern B.C. Several participants identified professional characteristics of themselves when describing why they were suitable for working in northern B.C. long-term. The characteristics included independence, confidence, flexibility, resourcefulness, and being comfortable in dual relationships. The results suggest long-term health care professionals in northern B.C. value the quality of life in the region and appreciate personal time with family and friends over money, status, prestige or material things. Participants often described themselves as adventurous and sociable, suggesting these are characteristics of long-term health care professionals in northern B.C. There were several similar factors identified across recruitment and retention, which were also reflected in the personal characteristics described by health care professionals. Nonetheless, there were important differences noted, especially across stages of career. The varying influence of these factors, the relationship of these factors across the stages of career, and how the findings fit into the current literature are described in Chapter 5. 80 Chapter 5: Discussion This research provides great insight into the reasons health care professionals choose rural training and initiate practice in northern B.C. The description of health care professionals who have already lived and worked in northern B.C., along with the identification of the influences that have kept them in the region long-term is essential to understanding recruitment and retention of health human resources in the region. The analysis of the factors associated with staying in northern B.C. informs health sciences student selection, potentially aids in the future creation of a rural suitability scale for selected health care professions, and provides evidence to inform recruitment and retention strategies for the health sector. This chapter discusses the major themes emerging from the interviews, and compares these findings to previous literature on this topic. This chapter first addresses the three research questions by identifying themes pertaining to (1) choosing rural or northern education, (2) initiating practice and staying long term as a health care professional in northern B.C., and (3) personal characteristics and experiences shared by long-term health care professionals in northern B.C. These themes are compared to the previous literature outlined in the introduction, highlighting what the current research adds to the understanding of rural and northern suitability. Lastly, personal values, age and stage of life, personal background, and location of family are explored in relation to understanding rural and northern suitability. 81 Choosing Rural or Northern Training There were two major themes that emerged in discussions related to rural or northern training. Table 2 Major Themes: Choosing Rural or Northern Training Major Themes Students choose rural education in preparation for practice Students choose education programs based on accessibility Choosing Rural or Northern Training A A The first theme suggests that the decision to work in a rural or northern setting was already made before taking part in a rural education component. Most of the previous literature suggests rural training increases the chances that health care professionals will choose northern or rural practice after graduation (Chan et al., 2005 Daniels et. al., 2007) and will remain in rural or northern communities (Barer & Stoddart, 1992; Dyck et al., 2007; Laven & Wilkinson, 2003; Lonne and Cheers, 2000; Peterson 1996). This study's findings suggest that rural or northern training helps prepare professionals for work in rural and northern areas, which in turn could positively affect job satisfaction and duration of practice, but does not guarantee retention. This finding is in agreement with findings by Henderson-Betkus and MacLeod (2004) who suggest rural education does not ensure duration of practice. This finding also parallels Chan et al. (2005) who noted students with rural upbringing already had interest in rural practice before any rural training. This finding also suggests students choose rural training because they already 82 plan to work in a rural or northern area and feel this choice would prepare them for future work. The second theme in relation to rural or northern training corresponds with previous research highlighting how northern institutions offering health care education programs increase the chances of local residents choosing health care professions (Johnson et al., 2006). Offering health care education to people who already live in the North has a positive impact on retention, as some participants have identified they chose their profession because the training was available in their region. This finding underlines the importance of providing health care education programs in regions where health care professional recruitment and retention is a problem. The findings suggest students are already planning on practicing in a rural or northern region when they choose rural specific training. The findings also suggest rural training has implications for recruitment and retention, as it prepares students for the challenges they may face and pushes them to recognize the supports that they will need to be successful in a rural or northern setting before they initiate practice. The findings also highlight the importance of having health care education programs accessible to local residents in areas where health human resources recruitment and retention is a challenge. Recruitment and Retention There were several themes in relation to both recruitment and retention. However, many of the factors that influenced recruitment also impacted retention. In this section, the themes that emerged in relation to both recruitment and retention will be discussed and compared in the following categories: (a) personal background and family factors, (b) professional factors, (c) individual factors, and (d) community factors. 83 Table 3 Major Themes: Recruitment and Retention Major Themes Recruitment Personal Background and Family Factors Past positive experiences A Growing up in a similar area Relationship with family Spouse A A A Retention A A A A Professional Factors Need for professionals Career advancement Friendly recruiters, employers, and peers Continuing education Inter-professional teams A A A A A A A A A A A A A A A A Job satisfaction Job security Liking employer Peer and managerial support Professional autonomy Opportunities to be creative Variety and challenges Individual Factors Adventure Recreation Beauty of the region A A A Social support and close friendships A A A A Community Factors Friendliness of rural and northern people Slower lifestyle A A A A 84 Shorter commutes Cost of living Quality of life Sense of belonging Desire to know people in community Safety of the community Community satisfaction Commitment to the community • • A A A A A A A A A Personal Background and Family Factors Similar to past research, this study found personal background played a role in recruitment (Brooks et al., 2002; Daniels et al., 2007; Easterbrook et al., 1999; Johnson et al., 2006; Laven & Wilkinson, 2003) and retention (Campbell & Gordon, 2003; Dyck et al., 2007; Henderson-Betkus & MacLeod, 2004; Mills & Millsteed, 2002). Past positive experiences in northern B.C., including growing up in the region, emerged as a major theme when talking to participants about the factors that motivated to them to come and stay in northern B.C. Growing up in a similar community, possibly in a different region or country, was also an emergent theme in both recruitment and retention. This finding is supported by Daniels et al. (2007), who suggest that working in their childhood town or even in a place that resembles the health care professionals' hometown has a positive impact on duration of practice. Relationship to family was also an emergent theme in both recruitment and retention discussions. Past research has suggested that proximity to family is influential in recruitment (Chan et al, 2005; Devine 2006; Hegney et al, 1997; Johnson et al., 2006) and in duration of practice (Campbell & Gordon, 2003; Henderson-Betkus & MacLeod, 2004; Mills & Millsteed, 2002; Schmidt & Klein, 2004). However, this study suggests the relationship quality along with the location of family influences recruitment. For example, participants who had family in northern B.C., and identified that being close to family is important to them, chose northern B.C. as a work destination and stayed longterm. In contrast, a couple of participants did not have good relationships with their parents who lived in other parts of Canada, and this drove them to come and stay longterm in northern B.C. away from their families. Family factors could have both negative and positive impacts on recruitment and retention depending on the quality of relationship and the location of family members. This study also noted that family factors change over time with age and stage of life. Several participants suggested that family factors were not as important to them in the recruitment stages, but after they had children of their own, family factors became a major influence in their retention. When discussing the influences of family factors in the recruitment phase participants focused on the relationship with their parents, but in the retention phase were more focused on relationships with their children and grandchildren. Similar to Henderson-Betkus and MacLeod (2004), this study suggests health care professionals who have children and want to raise their children in a rural or northern community are more inclined to stay. Parents often did not want to uproot their children from a community and this became a retention factor. Being married or having children influences family factors, and highlights how values change with age and stage of life. Establishing whether a health care professional highly values having children of their own and what values they have regarding raising their children inform predictions of the long-term intentions of a health care professional. For example, one participant 86 moved a lot as a child, living in both urban and rural areas. When she finished school, she got married and had children of her own. Her childhood experiences had shaped her family values and consequently, she wanted for her children what she did not have, which was to feel secure and grow up in one community. / moved around so much when I was a kid, so I really never had a home. It really anchored my roots here for me. The kids can tell that we are settled here and that gives them some security. And that was important for me. That they know that this is their home, these are your friends, and we are not going to pull you away from them. (Northeast) In congruence with previous literature, spousal factors also influenced both recruitment (Chan et al., 2005; Devine, 2006; Lonne & Cheers, 2000) and retention of long-term health care professionals in northern B.C. (Barer & Stodart, 1999; Dyck et al., 2007; Henderson-Betkus & MacLeod, 2004; Mayo & Mathews, 2006; Pathman, 2006; Sempowski et al., 2002). The theme suggests location of spouse's background, employment opportunities, and location of spouse's family influence recruitment and retention. Finding a spouse in the region was a recurrent theme in retention, along with spousal contentedness as noted in previous literature (Mayo & Mathews, 2006). Unlike past research, this study introduces the role of family values on the retention of health care professionals. Schmidt and Klein (2004) introduced the value of family and community connections as benefits of rural social work practice in comparison to urban practice. However, this research also highlights how family values change over time and how having your own family later in life can create further considerations for retention. Findings from the current study suggest that values, age and 87 stage of life, and location of family are interconnected with personal background to influence recruitment and long-term retention. Professional Factors The findings suggest several professional factors influence both recruitment and retention. Ironically, participants reported the supply and demand for health care professionals impact both recruitment and retention, as the lack of health care professionals in northern B.C. creates opportunities for career advancement. This is similar to past research which has found choosing rural practice is influenced by the need for health care professionals (Daniels et al., 2007) and career advancement possibilities (Devine, 2006; Lonne & Cheers, 2000). According to participants, some of the major influences in relation to choosing practice in northern B.C. occur during the job interview process. Unlike previous research, participants in this study reported friendly recruiters, employers, and peers were influential in their decision to come to this region. Similar to previous research, promises of opportunities for continuing education (Daniels et al., 2007; Mills & Millsteed, 2002) and to work with inter-professional teams (Devine, 2006) were also major themes during the current interviews when discussing recruitment. However, this study identifies that the age and stage of life and/or stage of career indicates how much these factors impact the decision. Dependant on age and stage of life and/or career, career factors held more or less weight on the decision to work in northern B.C. The major themes in relation to duration of practice included career advancement and continuing education, similar to those influences on recruitment. However, job satisfaction was more of a focus in the discussions about retention. Similar to previous 88 studies, job satisfaction and other professional factors that impact job satisfaction were related to duration of practice (Ingersoll et al., 2002; Pan et al., 1995). Similar to Henderson-Betkus and MacLeod (2004), this research highlighted the importance of career advancement, job security and employment benefits in the duration of practice for nurses. Mackenzie (2006) suggested social workers are more successful in rural areas if they appreciate a generalist approach, while Schmidt and Klein (2004) suggested rural social workers value a generalist approach more than urban social workers. This past research highlights that long-term health care professionals enjoy the variety of patients they see in northern B.C. and this has a positive impact on job satisfaction. Limited resources created challenges for long-term health care professionals, yet every one of the participants who mentioned this indicated that they had the ability to meet those challenges in creative ways. In these cases, limited resources became a source of satisfaction when they were dealt with successfully. This generalist approach and lack of resources challenge health care professionals' skills on a daily basis, allowing for continued learning and increased job satisfaction, which in turn have positive impacts on retention. The themes from this research also support past research that identified professional autonomy and self-reliance as key factors in retaining health care professionals in rural areas (Hegney et al., 2002; Wills & Case-Smith, 1996) and as benefits of working in rural regions (Schmidt & Klein, 2004). However, previous studies have found health care professionals chose rural practice in part because of the opportunity to be independent (Bates et al., 2005; Devine, 2006; Johnson et al., 2006) and the ability to be creative at work (Devine, 2006; Mackenzie, 2006; Wills & Case-Smith, 89 1996). This study found professional autonomy and the ability to be creative at work were not very common in recruitment discussions, but were major themes in discussions about long-term retention, which agrees with work by Mackenzie (2006) and Wills and Case-Smith (1996). Similar to past research, this study suggests peer and managerial support are very influential on the retention of health care professionals in rural and northern areas (Devine, 2006; Hays et al, 2003; Hegney et al, 2002; Mills & Millsteed, 2002; Wills & Case-Smith, 1996). Participants explained how their employers and their peers have a vested interest in the health of the community, making their own job much more fulfilling and satisfying. Their work is appreciated and they are applauded for trying something new and creative to get the job done. Many long-term health care professionals in northern B.C. truly value the work they are doing, respect the people they work for, and receive respect for their roles at work. The current research also suggests that health care professionals in northern B.C. appreciate the unique peer and managerial support found in the region. Participants highlighted the opportunities that allow them to really get to know their peers, work across disciplines, and community-based work. These findings are in agreement with earlier research and conference presentations, which highlighted the bridging of health service gaps by working across disciplines (Dyck, 2005; Wills & Case-Smith, 1996) and the opportunity to do community-based work as having an impact on retention (Dyck et al., 2007; Peterson, 1996). Among those few who did not feel respected by their employers, there was still an expression of commitment to their peers and to the health of their community. Participants suggested they did not highly value competition. Rather, participants 90 discussed their commitment to the health of their communities as a driving professional influence. Participants rely heavily on their abilities to communicate with their peers and to work across disciplines to nurture their professional support networks. The long-term health care professionals in northern B.C. are appreciative of their peers and of the human resources that they do have, highlighting how competition and professional status are valued less than the overall health of the community. Individual Factors According to participants in this study, the need for adventure was one of the major driving forces in choosing northern B.C. as a work destination and this has not been identified in previous research. A common theme throughout the interviews is the value in adventure, which brought people to the North, brought people back to the North, and kept people in the North. Many long-term health care professionals talked about their personal values, which include adventure, when discussing factors that have helped them to stay long-term in northern B.C., although the need for adventure was much more significant in discussions about recruitment. Other individual factors influencing recruitment, such as personal preferences for outdoor recreation and rural lifestyle, have been discussed in both the current study and the previous literature (Bates et al., 2005; Chan et al., 2005; Crump et al., 2004; Johnson et al., 2006; Kearl & Mainous, 1992; Lonne & Cheers, 2000). Parallel to that literature, personal preferences for outdoor recreation and rural lifestyle were also identified as factors in retention (Campbell & Gordon, 2003; Dyck, 2007; Lonne & Cheers, 2000; Peterson, 1996). Previous literature also highlights how openness to making friends has an impact on duration of practice in a rural or northern area (Dyck, 2005; Lonne & 91 Cheers, 2000; MacKenzie, 2006; Peterson, 1996). This was also identified in the current study, which recognized close friendships as a factor in retention. In addition, several past studies have highlighted friendships and social support systems as pertinent to understanding duration of practice (Barer & Stoddart, 1999; Hays et al., 2003; Hegney et al., 2002; Henderson-Betkus & MacLeod, 2004; Pathman, 2006; Sempowski et al., 2002). Many participants discussed the trade-offs associated with living in northern B.C. Many participants explained that they value living close to the wilderness and outdoor recreation more than living close to urban amenities and shopping. This is in accordance with work by Schmidt and Klein (2004) who found social workers identified living close to the wilderness and having access to outdoor recreation as beneficial to practicing in rural areas. Participants often appreciated the four distinct seasons more than the mild and moderate seasons further south. Participants described how prestige and status associated with materialism is less important to them than a casual, informal lifestyle. Many participants expressed that they value the time they save in commuting because they are able to spend more time with family. Money and professional status and the affordability of living in the north help them to achieve a quality of life that they prefer. Community Factors Similar to previous findings, the choice to work in northern B.C. was a lifestyle choice for several health care professionals (Hegney et al., 1997). The low real-estate prices allowed for more money for travel and other activities. Northern B.C. also offered friendly people and a relaxed lifestyle away from traffic, crowds and pollution of larger centers. These factors were also identified as themes in discussions regarding retention. 92 However, in retention discussions the quality of life was explained more in terms of time to spend with family and quality of life for children, which was highlighted by Mills and Millsteed (2002). Similarly, Schmidt and Klein (2004) noted one of the benefits of working in rural social work practice is the time saved by not having to deal with traffic and congestion. The current findings also highlight how the influence of community factors evolve over time and are inter-related with retention. Comparable to previous studies, participants illustrate how integrating into the community and taking part in community activities increases community satisfaction and feelings of belonging, which have a positive impact on retention (Barer & Stoddart, 1999; Campbell & Gordon, 2003; Hays et al., 2003; Henderson-Betkus & MacLeod, 2004; Lonne & Cheers, 2000; Pathman, 2006; Sempowski et al., 2002). The desire to know the people in their community and the feeling of safety associated with knowing the people in their community were also identified by participants in the current study. This is congruent with past research that suggests health care professionals stay in a community where they feel needed (Cutchin, 1997; Henderson-Betkus & MacLeod, 2004; Lahaie, 1991; Mayo & Mathews, 2006). Themes from the current study imply health care professionals stay long-term in northern B.C. when they value northern people and their communities, similar to research done by Peterson (1996). The current study highlights how community factors change with age and stage of life. For example, the longer a health care professional stays in a community, the more they feel a sense of belonging in the community. The longer they stay the more 93 committed to their community they become. The commitment to the community was identified as a major influence in duration of practice. That is key. They have to have a commitment beyond themselves. If they have a commitment to the community, they are going to stay because they have a stake in that. It is the people that come who really don't have a commitment and they are just here for the two years until their student loans are paid off and then they are gone! (Northern Interior) Summary The factors which influence recruitment and retention for long-term health care professionals in northern B.C. are very similar. However, the influences of family change from focusing on relationship and location of parents in recruitment, to relationship and location of children and grandchildren in retention. The number and variation of professional influences differ in recruitment and retention, with an increased value on job satisfaction in the decision to stay. As professionals learn more about their career and spend time with their employer, the deciding factors grow to include more characteristics of the job. Individual factors which influence recruitment and retention are very comparable; however, the introduction of how important social supports are to retention after professionals have spent time in a community is a major distinction. In addition, the first impression of a community and expected quality of life in a community holds more importance in recruitment, while community satisfaction, sense of belonging, and commitment to the community are motivations in retention. 94 Personal Characteristics and Experiences This research found a number of personal characteristics and experiences shared by long-term health care professionals in northern B.C., which were also reflected in the recruitment and retention of these individuals. The following table highlights the major themes pertaining to personal characteristics and experiences. Table 4 Major Themes: Personal Characteristics and Experiences Major Themes Past positive experiences in rural or northern communities Having family in northern B.C. Appreciates professional autonomy and independence Generalist Enjoys feeling of belonging in a community Resourceful & creative Flexible Comfortable with dual relationships Appreciates outdoor recreation Down to earth Sociable and approachable Adventurous Committed to the community Appreciate sense of belonging Personal Characteristics and Experiences Shared A • • A • • A A • • A • • A In accordance with past suggestions (Brooks et al., 2002; Dyck et al., 2007; Easterbrook et al., 1999; Henderson- Betkus & MacLeod, 2004; Johnson et al., 2006; Laven & Wilkinson, 2003; Lonne & Cheers, 2000; Peterson, 1996), having had past 95 positive experiences in rural or northern areas, as well as having family in the region was emphasized by participants in the present study. Appreciating professional autonomy, independence and a generalist view (Campbell & Gordon, 2003; Dyck, 2005; Hegney et al., 2002; Johnson et al., 2006; Mackenzie, 2006; Wills & Case-Smith, 1996;) were also common characteristics identified by participants and found in the literature. As in other past research, being fond of outdoor recreation found in the region (Johnson et al., 2006) and the feeling of belonging in a community (Henderson-Betkus & MacLeod, 2004) were underscored by participants in this study. One of the major themes identified by long-term health care professionals in northern B.C. is that they are resourceful. This finding was also brought to light by Dyck (2005) and Wills and Case-Smith (1996). Creativity was also put forward as a personal characteristic shared by long-term health care professionals in the study and this is also supported by past research (Mackenzie, 2006; Peterson, 1996; Wills & Case-Smith, 1996). The ability to be flexible at work was also highlighted by long-term health care professionals and reinforced in previous literature (Dyck, 2005; MacKenzie, 2006). In the current study, several long-term health care professionals described themselves as down to earth which was also a characteristic highlighted by Dyck (2005). Also similar to previous findings, long-term health care professionals suggested that they needed to be sociable, approachable, willing to make friends, and comfortable with dual relationships (Campbell & Gordon, 2003; Dyck, 2005; Lonne & Cheers, 2000; Mackenzie, 2006; Peterson, 1996). Previous findings also suggest long-term health care professionals in rural and northern areas are comfortable with personal and professional boundaries (Campbell & Gordon, 2003; Dyck, 2005; McKenzie, 2006). Having the ability to work with dual relationships was also outlined in the current study as a personal characteristic of a long-term health care professional in northern B.C. The current research also suggests long-term health care professionals are adventurous, committed to their community, and they appreciate a sense of belonging in their community. Although the research outlines a number of personal characteristics and experiences identified by long-term health care professionals, it is not one particular factor over another that appears to dictate duration of practice in northern B.C. More so, a combination of varying values and trade-offs help dictate length of practice in northern B.C. For example, someone who likes wide open spaces more than crowds, is not necessarily more likely to live long-term in northern B.C. Someone who really enjoys shopping and fashion is not necessarily less appreciative of all that northern B.C. has to offer. However, it appears that health care professionals become long-term residents of northern B.C. when particular combinations of factors create the most personal value. The factors are fluid and relational to age and stage of life, and a progression of values, rather than a fixed set of personal characteristics and experiences. Personal Values Initial projections indicated that this study would identify a set of personal characteristics and experiences shared by selected, long-term health care professionals to inform student selection by health care education programs. Nonetheless, the current study findings suggest that staying in northern B.C. to practice as a health care professional is more about personal values than personal characteristics and experiences. The themes suggest personal values are heavily influenced by personal characteristics and experiences, and as such impact duration of practice in northern B.C. However, personal characteristics and experiences are trumped by personal values and age and stage of life in the decision to come and stay in the region. Age and Stage of Life Both recruitment and retention rely heavily on the age and stage of life people are in. As people grow, their personal values change. This change is very apparent in the comments of one interviewee who moved to northern B.C. solely because of her love for skiing and hiking, and planned to stay only a couple of years. She explained how her decision was based on her recreational interests which, at that time in her life, were most important to her. My reasons for being where I am are purely for the age and the time that I was at... I wanted to be in a recreational town. (Northwest) However, within the first year, she met her future husband and a group of friends who also liked to ski and hike. Not only did she want to stay in a community where she could ski and hike, she wanted to stay close to her future husband and friends. Her new social support network became the most highly valued aspect of her life at that time. As she continued to work in the community, she started to feel like she belonged to that community and that her community needed her services. When she married and had children, her values shifted again. She still enjoys skiing, hiking, and hanging out with friends, but now she wants to stay in the community because she values raising her children in a rural, northern community. Over time, her values have evolved; as the value of her role in the community increases, so does her sense of belonging. Thus, she places more value in that community and wants to raise her children there. 98 As this participant outlined, personal values change over time with age and stage of life. Therefore, one major finding is that determinants are not static. The expected specific characteristics and experiences are common to some long-term health care professionals in northern B.C., but the age and stage in life determine the weight of these factors on their decisions to both come to, and remain in northern B.C. As another longterm northern B.C. health Care professional explains: When I was just getting out of school, I had an opportunity to take a bursary and work in a northern community. For all I know, it could have been here! Umm... but at the time, I was single and still finishing school and I was terrified (laugh) to leave the Lower Mainland! So, I took the bursary. It was all set up and then I backed out. I said, "I don't think I can do this! I don't want to go to a northern town and be all by myself and have nothing to do! It will be freezing cold! " And I backed out. When this opportunity to come to [northern B.C. community] came up, we were coming here as a family. (Northeast) Rural or Northern Background According to the interviewees, personal background plays a big role in both recruitment and retention of health care professionals in northern B.C. However, it does not appear that a rural upbringing or experience in rural areas indicates definite long-term retention. Yet, rural upbringing or experience in rural areas does appear to influence personal values, which can affect long-term retention. For example, participants who grew up in a rural community indicate they were exposed to the benefits of living rurally. i For these participants, growing up close to the wilderness and those types of experiences nurtured their passion for outdoor recreation. For others, growing up within a tight-knit community created feelings of security inherent in knowing all of their neighbours. Further, values change with the age and stage of life, suggesting that the impact of rural upbringing on recruitment or retention is dependant on age and stage of life. / guess that as I got older, I have grown to see the benefits of what a small community can be. When I was younger, it felt like that it could have been a bit stifling. When I went away to college and then to university and then came back, I realized that it wasn 't so much stifling as it was supportive. (Northwest) In addition, experiences shape our world views. The more time someone lives in a northern region, the more it becomes the norm for that particular individual. Their behaviours adapt and their personal values are influenced. When a health care professional grows up in a rural or northern community, goes to university in a rural or northern community, or has work experience in a rural or northern community, these experiences will shape both their behaviours and values. They may realize they do not mind living far from large shopping centers, or they may come to enjoy living close to lakes and mountains. The importance of shopping may decrease for them, as the importance of living close to the wilderness increases. Their experiences influence their behaviours and values. The findings suggest age and stage of life have a significant impact on personal values, which in turn affect the decision to come and/or stay in northern B.C. Location of Family Members Similarly, location of family members has a varying impact on recruitment and retention depending on age and stage of life, and how much the interviewee values living close to (or in some cases away from) their family members. If health care professionals are married, the location of their spouses' family needs to be taken into account. For example, more than one surveyed health care professional came to northern B.C. for an adventure in their early twenties. During that time, they valued adventure more than living close to their families. However, now with spouses and possibly children, living close to extended family, on either side, is more of a factor for them to stay in the region. Being close to extended family has become more important to them over time. For others, living close to family is valued over mostly everything else regardless of age and stage of life. This need to be close to family trumps career aspirations, their love of theatre and/or their need for adventure. For these people, location of family is a major indicator for recruitment and retention regardless of other personal characteristics, experiences, and other values. As such, location of family needs to be identified before considering personal characteristics, experiences, and values. Summary Themes pertaining to (1) choosing rural or northern education, (2) initiating practice and staying long-term as a health care professional in northern B.C., and (3) personal characteristics and experiences shared by long-term health care professionals in northern B.C. were explored. An investigation into the influences on choosing rural practice suggests students who choose rural training are already planning to practice rurally and choose rural training to prepare them for future work. The results imply that students also choose rural education or rural professions based on accessibility of educational programs. According to the findings, factors that influence recruitment of health care professionals to northern B.C. are very similar to the factors that keep health care 101 professionals in the region. The factors that influenced recruitment also influenced retention. However, retention was also affected by a number of other factors. For example, many participants named factors associated with job satisfaction as motivation for staying in northern B.C., but this was not identified as a factor in recruitment. This is easily explained by the fact that health care professionals can only understand how satisfied they are with the position once they have had experience doing that job. Similarly, community factors, including feelings of belonging and commitment to the community, were only identified as motivations to stay, not as influential in the decision to come to northern B.C. It can be assumed that the professionals need experience within a community in order to identify these factors as influential. The analysis unveiled a number of personal characteristics and experiences shared by long-term health care professionals. However, the analysis of the findings suggests it is not one particular factor over another that appears to determine duration of practice in northern B.C. The results of the study imply a combination of varying personal values impact the decision to come and/or stay in northern B.C. Personal characteristics and experiences help to shape these personal values. Age and stage of life, rural background, location of family members also have bearing on personal values, which in turn impact recruitment and retention. Chapter 6: Conclusion Recruiting and retaining of health care professionals to Canada's rural and northern areas is one of the health care system's greatest challenges (Decter, 2005). With new health sciences programs designed to train students who are more likely to stay in rural and northern areas after graduation, student recruitment and selection will focus not only on those applicants who have the capability to complete the programs, but who are also suitable to work in rural and northern areas after graduation. The primary objective of this project was to identify personal characteristics and experiences shared by health care professionals who have already worked in northern B.C. long-term to potentially create a suitability component for health education program selection criteria. This study explored the factors that motivated health care professionals to choose rural training, come and stay in northern B.C. long-term. Six speech-language pathologists, 4 psychologists, 4 occupational therapists, 8 social workers, and 4 physiotherapists were interviewed in northern B.C. The participants came from a variety of rural and urban backgrounds; almost half of the participants had originally come from a city with a population of more than 100,000 people. A qualitative descriptive design was used to identify participants' motivations for choosing rural or northern training, initiating practice in northern B.C., and remaining in the region. The findings suggest personal characteristics and experiences, along with age and stage of life, rural background and location of family influence personal values about family, career, personal preferences, and community. Personal values determine the decision to come and/or stay in northern B.C. 103 Conceptual Model for Understanding Rural and Northern Suitability The major theme emerging from this research is that factors influencing both recruitment and retention are not static; rather they are fluid and always changing. Personal values related to family, career, personal preferences, and community all have varying impacts on the decision to come and stay in northern B.C. Personal characteristics and experiences help to shape these personal values, and as such impact duration of practice. However, it is not personal characteristics and experiences alone that determine either recruitment or retention. Over time and depending on stage of life, personal values change. The amount of value given to career earlier in life may decrease as family values increase in value later in life. For example, a health care professional could move to a community based on personal preference for skiing. However, later on in life, family factors may have more influence over where the health care professional decides to work. Rural background and the amount of time one spends in a rural or northern area will also have an effect on personal values. The more time a health care professional spends in northern B.C., the more personal values will be impacted by experiences. Therefore, rural background indirectly influences both recruitment and retention of health care professionals. The location of family members needs to be identified when trying to understand rural and northern suitability because the location of family members, along with family values, could potentially influence recruitment or duration of stay. The emergent themes in this study suggest personal characteristics and experiences help shape personal values related to family, career, personal preferences, and community. The current study also suggests values evolve over time and depend on the age and stage of 104 life. Past experiences in rural and northern areas also help shape personal values. The following model depicts how age and stage of life, rural background, location of family members and personal characteristics and experiences shape personal values, which in turn affect both the decision to come and stay in northern B.C. Figure 1. Conceptual Model: Understanding rural suitability Personal Values Related to: In summary, the age and stage of life, rural background, and location of family members set the stage for understanding how personal values impact decisions to come and stay in northern B.C. Meanwhile, personal characteristics and experiences help shape personal values, but age and stage of life create a priority system that more strongly influences both recruitment and retention. The most important themes suggest factors that 105 influence duration of practice are not static, as personal values are fluid and depend on the age and stage of life. Recommendations The results of these interviews have implications for education programs and rural communities, as well as employers interested in selecting, recruiting, and retaining health care professionals who will stay long-term in rural and northern regions. The following are the recommendations based on the findings from the current research. Health Education Programs The major recommendation for health education programs that aim to retain health care professionals in rural and northern areas is that they need to be in rural and northern areas and be accessible to the people who already live in the region. Further, these health education programs need to include rural or northern issues in the curriculum and rural or northern placements for the practicum to prepare health care professionals to work in the region. When health education programs aspire to select students who will remain in rural and northern areas, they need to consider a number of factors. Identifying age and stage of life, personal background, and location of family will help understand rural and northern suitability. Health education programs need to look at family values, such as the quality of relationships the applicant has with parents and siblings. If the applicant has children or wants to have children, identifying the kind of environment they would like to raise their child in is also very important. Understanding professional preferences will also help to select suitable candidates. Depending on the applicant's stage of career, the preferred level of guidance, support, and professional autonomy is important to identify. To understand suitability, 106 education programs can explore the applicant's preference for variety and challenges. Identifying if the applicant appreciates change and being creative at work could also help understand suitability. Lastly, to help understand the rural and northern suitability of applicants, education programs should try to determine personal preferences in relation to recreation, rural living, and quality of life. The University of British Columbia Northern Medical Program housed at UNBC currently uses a Rural Suitability Scale (Johnson et al., 2006) in their application process. Based on the current research findings, a similar scale could be used for other health care education program selection criteria. However, these research findings suggest health care education programs for the selected health care professionals should consider how personal values change over time. Understanding student applicants' age and stage of life is important to consider. The Rural Suitability Scale gives extra points for 'family connections' in northern B.C. (Johnson et al., 2006); the current research suggests health care education program selection criteria should also identify applicants' relationship to family, the location of other family members, as well as age and stage of life. The Rural Suitability Scale also appears to favour maturity due to implied self-reliance in mature students (Johnson et al., 2006). The current research on selected health care professionals suggests those applicants who prefer professional autonomy and value independence would be suitable; however, the findings also highlight how this value changes with age and stage of life and with experience on the job. Therefore, if the Rural Suitability Scale was used for the selected health care professional education programs, it should not solely favour maturity; rather, the application process should consider the potential for independence and professional autonomy at work, as well as consider family location and family values to assess suitability. Overall, the Rural Suitability Scale used in the Northern Medical Program could also be useful in assessing suitability of selected health care professionals for northern B.C. communities if a number of changes were made and the evolution of personal values was considered. In any assessment of suitability, one needs to consider the implications for student or employee fairness and human rights. Northern B. C. Communities Community factors play a big part in both the recruitment and retention of health care professionals in northern B.C. Therefore, community members should advertise the benefits of living in the community and the recreation available in their area in order to help recruit health care professionals to their community. Community members can get involved in welcoming new recruits by inviting them to community activities, such as barbeques, dances, choirs, and sports events. Helping to integrate new health care professionals into the community will increase the commitment they have to the community, and consequently help with retention. Health Employers The recruitment and retention of health care professionals is multifaceted. Selecting a suitable health care professional for the job depends on the combination of personal values, age and stage of life, personal background and the location of family members. This implies that health employers should try to identify these factors when selecting new health care professionals for the northern B.C. region. The findings also have implications for the recruitment of these selected health care professionals. The findings suggest health employers need to highlight the career 108 advancement opportunities available in northern B.C. when trying to recruit new health care professionals to the area. The interview process is very important to the decision to choose northern B.C. as a work destination; the findings suggest the employers' friendliness and the availability of a peer support system during the recruitment process have a positive effect on recruitment success. Further, the findings highlight the need for employers to invest both time and money into continuing education and interprofessional team building to help with both recruitment and retention. The current study also suggests health employers need to focus on increasing their employees' job satisfaction to help with long-term retention. Creating a supportive environment, while allowing health care professionals to have independence, flexibility, and control over their own position is very important. Investing money into offering permanent, full-time positions with benefits and vacation time, instead of temporary or casual employment is very important to retention. This is something that should be considered as the baby-boomer generation begins to retire and leave vacancies in health care professions across the province. Limitations There were two potential limitations due to the particular sample used in this research project. The first is that it only included selected health care professionals in northern B.C.; therefore, the results of this study may have regional influences and not be generalizable to other rural and northern areas or to other professions. The second potential limitation is the small sample size, which may not be representative of the entire population and was too small to permit the assessment of differences between professional groups, including gender, level of education, or pay scale. However, this study is meant to be an exploratory, in-depth assessment of the influences affecting selected health care professionals in northern B.C. Saturation was achieved and the data were rich with information, suggesting the purpose of this study was achieved in consideration of the time and resources available for this graduate thesis project (Patton, 2002). There were also potential biases due to the method used in this research project. The first possible limitation comes from the effects of retrospective reporting and recall bias, as participants were asked to report on their memory of past events. The interviews may also have been subject to reactivity of the interviewee to the interviewer (Patton, 2002). Lastly, I performed all of the interviews and the analysis, suggesting the potential for observer bias and selective perception of the data (Patton, 2002). The potential limitations of the method used emphasizes why it was important to not only do extensive member-checking and compare current findings to previous literature, but to also include an external audit to validate findings (Creswell, 2005). Future Research This next step toward understanding suitability for northern B.C.'s student selection and health care professional recruitment is to conduct further research. The current findings pertaining to long-term health care professionals need to be compared to other health care professionals who leave northern B.C. after a relatively short period of time. This could be done by asking health care professionals similar questions about their motivations for choosing northern B.C. and leaving northern B.C. when they go through their exit interviews. That is, some of the health organizations in northern B.C. perform exit interviews with employees to ask about their reasons for leaving their 110 position when they decide to leave. Exit interviews could include questions about their personal values in relation to family, career, personal preferences, and community, as well as age and stage of life, personal background, and location of family members. Comparing the findings from this study to the information collected from short-term health care professionals in their exit interviews is recommended for future research. The current findings pertaining to long-term health care professionals in northern B.C. should be compared to health care professionals who have stayed long-term in metropolitan centers. Long-term health care professionals in metropolitan centers should be asked similar questions about their motivations for choosing urban practice and remaining in urban practice. The interviews should be tailored to identify personal values in relation to family, career, personal preferences and community, as well as age and stage of life, personal background and location of family members. This study also needs to be elaborated using a quantitative design to include a larger number of various health care professionals in other rural and northern regions. To increase the generalizability and breadth of the current findings, a survey could be created to ask a variety of health care professionals in rural and northern areas of Canada about their motivations for choosing rural or northern practice, and staying long-term in their region. Again, the questions should focus on the personal values in relation to family, career, personal preferences, and community, as well as age and stage of life, personal background, and location of family members. This would increase generalizability and would allow for the detection of possible differences between health care professionals, gender, or pay scale that were otherwise undetectable in the current study. Ill Lastly, these findings need to be compared to the Northern Medical Program's findings once their longitudinal study of where their graduates decide to stay and practice has been completed. The development of a rural suitability scale for the selected health care professionals based on the current study's findings should be considered in the future. A longitudinal survey that follows new recruits or health care students over time, documenting the change in values with the age and stage of life, would also be helpful. Summary In summary, the current study identifies a number of exciting topics for further research into rural and northern suitability to health professionals. 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Retrieved August 11, 2007, from the British Columbia Ministry of Health Web Site: http://72.14.253.104/seai-ch?q=cache:zV381qTCMqkJ:wwwl.hlth.gov.bc.ca/rural/ pdf/NMP Report Final.pdf+building+for+the+future+of+health+care+in+norther n+bc&hl=en&ct=clnk&cd= 1 & gl=ca Wills, K., & Case-Smith, J. (1996). Perceptions and experiences of occupational therapists in rural schools. American Journal of Occupational Therapy, 50(5), 370-379. Appendix A Map of Northern B. C. by Health Service Delivery Area Q) • ••'.'/• r J' V* . - - .. :.*^™^ lt - --- - --., .. . .H&. N o r t h e r n Health Service De!i¥«rv Area ; i 8WMii# ttSMIiSit - . % 1m I I ^g. \ w (jL V - ' Nurt&ern Inl^rior H^iHh Swmce Delivery Arsa E Northwest H « I i h Sesvi» Delivery Aw>.» n *** **$« : (Map from the Northern Health website http://www.northernhealth.ca/About/) 123 Appendix B The Decision to Stay or Leave __,^^^__g_> Filter Factor: Opportunities Decision to Stay or Leave From "Retaining Public Health Nurses in Rural British Columbia: The Influence of Job and Community Satisfaction" by M. Henderson-Betkus and M. L. P. MacLeod, 2004, Canadian Journal of Public Health, 95(1), p. 54. Permission to use this figure granted by Mary Henderson-Betkus, April 2007. 124 Appendix C Summary of Literature Review Findings 125 Summary of Literature Review Findings Factors Physician Recruitment Physician Retention Nurse Recruitment Nurse Retention Selected Health Care Professionals Recruitment Rural curriculum Rural practicum Financial incentives Job satisfaction Professional support networks or managerial support Family friendly work environment Challenges in rural/northern practice settings Variety of work/ choosing a generalist approach to practice Opportunity to make decisions/ independence/ autonomy at work Potential career advancement or employment opportunities Growing up in a rural or northern X mixed X mixed X X mixed X X Selected Health Care Professionals Retention X X X X X X X X X X X X X X X X X X X X X X X X X X X 126 community Past, positive experiences working in a rural or northern community Family living in a rural or northern community Friends living in a rural or northern community A mentor living in a rural or northern community A spouse who is from a rural or northern community A spouse who appreciates living in a rural or northern community A spouse who has a career opportunities in the community A spouse who has family and or friends in the community The friendliness of the community Belong to a community/ getting involved with the X X X X X X X X X X X X X X X X X X X X X X X X X X X X X 127 community/ community satisfaction The "safety" of living in a rural or northern community The social support networks in the community The need for health care professionals in rural and northern communities Comfortable with having dual relationships/hi gh profile in community The outdoor X activities and recreation available in the community The slow pace X of rural living ("relaxed lifestyle") Inexpensive real estate prices Access to education X 1 X X X X X x: X X mixed X X X X X X X X X Note: "X" means the factor was identified as an influence in the literature review. "Mixed" means the factor was identified as an influence in some of the literature, but not an influence in other literature. A blank cell indicates it was not identified as an influence in any of the literature reviewed. Appendix D Screening Questions 1. Where do you work? a. In North East British Columbia (East of MacKenzie, includes areas around Chetwynd, Dawson Creek, Fort St. John, Fort Nelson) b. In Northern Interior of British Columbia (Includes areas around Prince George, Quesnel, Burns Lake) c. In North West British Columbia (West of Burns Lake, includes areas around Terrace, Prince Rupert, Bella Coola, Queen Charlotte Islands) 2. What is your main profession? a. Occupational therapist b. Physiotherapist c. Psychologist d. Social Worker e. Speech Language Pathologist f. Other 3. How long have you worked in your profession in current community? years months 4. Do you plan to remain working in northern B.C.? 129 Appendix E Interview Questions Interview Questions I wanted to talk to you today because you have lived and worked in northern B.C. as a health care professional for a long time and you don't plan to leave. I think that is great and I also think we need to find more people like you! I suspect that there are certain characteristics that make you suitable for living and working in northern B.C. I think there is a certain kind of person who enjoys working as a health care professional in the north, so I wanted to ask you about your experiences and observations. Section 1 I would like to ask you a few personal questions to start out... 1. Are you originally from northern B.C. ? (Defined by Northern Health) a. How would you describe your childhood hometown? 2. How much of your life have you spent in this region? a. If applicable, how about in your current community? 3. Are you currently married or living in a common-law relationship? a. If so, is your spouse satisfied with your current community? Are there any opportunities for your spouse here in this region? b. Are they originally from northern B.C.? c. What best describes your spouse's childhood hometown? 4. Do you have children? a. If yes, how many? b. What are the age(s) of your child(ren)? c. If applicable, are your children satisfied with your community? d. Are there any opportunities here for your children? 5. How far away do you live from your mother? a. If applicable, your spouse's mother? 6. How far away do you live from your father? a. If applicable, your spouse's father? 7. Do you have any other family members living in this region? How about your friends? Section 2 The next few questions are about your time spent in northern B.C.. 8. What portion of your life have you spent in northern B.C.? .years months 9. What portion of your career have you spent in northern B.C.? years months 10. Do you plan to remain working in northern B.C.? (Please remember this interview is completely confidential and anonymous) 11. Where did you do your health care education? a. Coursework? b. Practical training (practicum, clinical placement, internship etc.) c. Did you learn about rural health during your education? d. Did you learn about any of the issues specific to this region, such as Aboriginal health? Section 2a (If trained in an urban setting, skip Section 2a and move on to Section 3.) Alright, I am going to ask you to think back to your training (and/or practicum). 11a. What was important in your decision to choose rural training or rural practicum? Probes: How important was that for you? Is there anything else that motivated you to choose rural training or practicum? (Repeat) How long were your training and/or practicum? Section 3 Now I would like to talk about your reasons for coming to work in northern B.C. 12. What was important in your decision to start working in northern B.C.? Probes: How important was that for you? Is there anything else that motivated you to start working in northern B.C.? (Repeat) 13. How about the region itself, is there anything about the region that really attracted you and/or your family to this region? 14. Is there anything that you moved away from or escaped by moving to northern B.C.? 15. If applicable, is there anything about the job itself that drove you to choose this region? 132 Section 4 And lastly, I would like to talk to you about what keeps you working here in northern B.C. 16. What is important in your decision to continue working here? Probes: How important was that for you? Is there anything else that motivated you to stay working in northern B.C.? (Repeat) 17. Now like I had said earlier, I think there is a certain kind of person who fits in here in northern B.C. You seem to 'fit in', as you have lived here long-term. Why do you think you fit in here? What is it that makes you the kind of person who stays in this region? Thank you for participating in this interview! Your time and efforts are greatly appreciated. 133 Appendix F Interview Information Sheet Researcher's name: Candice Manahan Supervisor's name: Dr. Cindy Hardy Address: Graduate Student Office, 3333 University Way, Prince George B.C. V2N 4Z9 Phone No: (250) 640-1040 E-mail: manac000@unbc.ca "Who Works In Northern B.C.?" Identifying Personal Characteristics And Experiences Shared By Long-Term Health Professionals In Northern British Columbia My name is Candice Manahan and I am a long term resident of Prince George. I grew up in northern B.C. and have always thought that it took a certain kind of person to work in this region. I am now a graduate student at the University of Northern B.C. and I am interested in finding out just what kind of person works as a health professional in B.C.' s northern region long term. With the creation of new health sciences programs to serve northern B.C., student recruitment will focus on those who not only have the capacity to complete the programs, but also those who are likely to stay and practice in northern B.C. The primary objective of this thesis project is to identify personal characteristics and experiences shared by health care professionals that live and have worked in Northern B.C. long term. The results of this research will guide the future development of an assessment tool for the recruitment of health care professionals and health sciences students in rural, northern B.C. The major benefit of participating in this study will be the opportunity to help the health human resources issue in northern B.C. There is low risk associated with participating in this study. There are no significant risks associated with participating in this study. You have been chosen to participate in this interview because you are a long term resident and health care professional in Northern B.C. You will be asked to keep an appointment with the researcher and participate in a thirty minute, telephone interview. The interview will be recorded with an audiotape and transcribed. Only myself and my supervisor will have access to the audiotapes and the transcription. This interview is completely voluntary and you have the right to withdraw from the interview at any time during the interview. If you choose to withdraw from the study at anytime, your information will also be withdrawn. If there is any question you do not feel comfortable answering, you have the right to skip the question. Unfortunately, there is no remuneration for participating in the study, but it should take less than thirty minutes to complete. Your anonymity is ensured; as your name and consent form will be kept separately from the interview data. Only my supervisor, Dr. Hardy, and I will have access to your interview record. Nothing that could identify you will be published. The interviews are completely confidential and the interview data will be kept in Dr. Hardy's lab at the University of Northern British Columbia in a locked cabinet that only she and I will have access to. The information will be stored in the locked cabinet for seven years, when I will pull the tapes apart and erase the transcript data. 134 If any questions arise about the interview or the findings, feel free to email or telephone me. The contact information is provided above. If you would be interested in receiving a summary of the study's results, please check the box on the consent form and provide an email or postal address. For more information about this study, please contact Dr. Cindy Hardy at (250) 960-5814. If there are any complaints about the project, please direct them to the UNBC Office of Research, 9605820 or by email: reb@unbc.ca. Please keep this copy for your reference and you will also receive a copy of your signed consent form. 135 Informed Consent Identifying personal characteristics and experiences shared by long-term selected health care professionals in northern British Columbia Do you understand that you have been asked to be in a research study? o Yes • No Have you read and received a copy of the attached information sheet? D Yes • No Do you understand that the research interviews will be recorded? • Yes • No Do you understand the benefits and risks involved in participating in this study? • Yes • No Have you had an opportunity to ask questions and discuss this study? • Yes • No Do you understand that you are free to refuse to participate or to withdraw from the study at any time? You do not have to give a reason. • Yes • No Has the issue of confidentiality been explained to you? • Yes • No Do you understand who will have access to the information you provide? • Yes D No Would you like a copy of the results summary? If so, please provide an email or postal address here: • Yes • No This study was explained to me by: Print Name I agree to take part in this study: Date: Signature of Research Participant Printed Name of Research Participant Date: Signature of Witness Printed Name of Witness I believe that the person signing this form understands what is involved in the study and voluntarily agrees to participate. Date: Signature of Investigator Appendix G Ethical Approval UNIVERSITY OF NORTHERN BRITISH COLUMBIA RESEARCH ETHICS BOARD MEMORANDUM To: CC: Candice Roberge Cindy Hardy From: Greg Halseth, Chair Research Ethics Board Date: November 8, 2007 Re: E2007.1022.124 Who is best suited to work in northern BC? Thank you for submitting the above-noted research proposal and requested amendments to the Research Ethics Board (REB). Your proposal has been approved. We are pleased to issue approval for the above named study for a period of 12 months from the date of this letter. Continuation beyond that date will require further review and renewal of REB approval. Any changes or amendments to the protocol or consent form must be approved by the Research Ethics Board. Good luck with your research. Sincerely, Greg Halseth