IntroductionFaced with a backdrop of an increasing chronic disease burden from an ageing global population compounded with rising healthcare costs, health systems are required to implement cost-effective, safe and equitable...

Health care provider retention is important for mitigating workforce shortages in underserved areas. The National Health Service Corps (NHSC) provides loan repayment for a two or three-year service commitment from clinicians to work in underserved areas. Prior studies have mixed findings as to what influences clinician retention and have focused mainly on individual-level background characteristics. We used measures of NHSC clinicians' work environment during their service experience, in addition to background characteristics, to identify patterns of experiences, and assess whether these patterns were associated with post-service intentions. We observed that technical assistance and job resources were more influential on clinicians’ intentions, compared to individual- or community-level characteristics. Organizations with efficient and supportive work environments may help retain clinicians in underserved areas.

Barriers to adequate healthcare in rural areas remain a grand challenge for local healthcare systems. In addition to patients' travel burdens, lack of health insurance, and lower health literacy, rural healthcare systems also experience significant resource shortages, as well as issues with recruitment and retention of healthcare providers, particularly specialists. These factors combined result in complex change management-focused challenges for rural healthcare systems. Change management initiatives are often resource intensive, and in rural health organizations already strapped for resources, it may be particularly risky to embark on change initiatives. One way to address these change management concerns is by leveraging socio-technical simulation models to estimate techno-economic feasibility (e.g., is it technologically feasible, and is it economical?) as well as socio-utility feasibility (e.g., how will the changes be utilized?). We present a framework for how healthcare systems can integrate modeling and simulation techniques from systems engineering into a change management process. Modeling and simulation are particularly useful for investigating the amount of uncertainty about potential outcomes, guiding decision-making that considers different scenarios, and validating theories to determine if they accurately reflect real-life processes. The results of these simulations can be integrated into critical change management recommendations related to developing readiness for change and addressing resistance to change. As part of our integration, we present a case study showcasing how simulation modeling has been used to determine feasibility and potential resistance to change considerations for implementing a mobile radiation oncology unit. Recommendations and implications are discussed.

In 2005, Mountain Area Health Education Center (MAHEC) collaborated with community partners to establish the Minority Medical Mentoring Program (MMMP), a semester-long health care pathway internship for high school seniors of color. This evaluation aimed to assess program participants' perceptions of program components, identify areas for improvement, and broaden the evidence base of pathway programs. Seventy-three MMMP alumni were invited to participate in an online survey. Closed- and open-ended questions aimed to assess respondents' perceptions of program components and MMMP's impact on their personal and professional lives. Forty-six alumni responded to the survey. The MMMP was perceived as universally valuable. Clinical shadowing, mentors of color, and exposure to a variety of health professionals were viewed as the most valuable program components. The MMMP strengthened participants' awareness of health disciplines, improved their self-confidence, and increased their professional skill sets. Surprisingly, the MMMP enabled some participants to recognize health career interests outside of clinical care. Selection, social desirability, and recall bias may limit interpretation of findings. The MMMP is highly valued by participants. A high majority of respondents (40/46; 87%) plan to have a health career in the future. Pathway programs can shape career paths, increase self-awareness, and build self-confidence for success. It is important to note that systemic racism and discrimination must be addressed to fully ensure recruitment and retention of health care providers of color.


 A targeted search was conducted to identify rural health care service planning initiatives and programs, frameworks for planning rural health care service delivery, and models of care used to deliver rural health care services.
 Identified planning initiatives and programs included team-based care, financial incentives for care providers, programs for international medical graduates to practice in rural areas, and new models of care.
 Identified frameworks and recommendations for planning rural health care service delivery included components such as taking a community-specific approach, multidisciplinary team-based care, developing and expanding use of telehealth, establishing evaluation methods, and improving the recruitment and retention of health care providers in rural areas.
 Identified proposals for models of care for rural areas included team-based care, models led by community health workers, and alternatives for hospitals.

Moral distress is well-documented among civilian critical care nurses and adversely affects patient outcomes, care delivery, and retention of health care providers. Despite its recognized significance, few studies have addressed moral distress in military critical care nurses. To refine and validate an instrument to assess moral distress in military critical care nurses. This study examined moral distress in military critical care nurses (N = 245) using a new instrument, the Measure of Moral Distress for Healthcare Professionals-Military (MMD-HP-M). The psychometric properties of the refined scale were assessed by use of descriptive statistics, tests of reliability and validity, exploratory factor analysis, correlations, and qualitative analysis of open-ended responses. Initial testing showed promising evidence of instrument performance. The Cronbach α (0.94) suggested good internal consistency of the instrument for the overall sample. Scores for the MMD-HP items and the MMD-HP-M items showed a strong, significant correlation (α= 0.78, P < .001). Unique attributes of military nursing that contribute to moral distress included resource access, futile care, and austere conditions. Exploratory factor analysis established a new military-centric factor for question items associated with inadequate training for patient care, providing care in resource-limited settings, and personal exhaustion. These results will help guide specific, targeted interventions to reduce the negative effects of moral distress on our military health care providers, especially in terms of readiness for the next global pandemic and retention of these invaluable personnel.

This study attempted to identify the impact of internal work environment on the retention of healthcare providers at Turaif General Hospital in the Kingdom of Saudi Arabia. In particular, the study aimed to identify the dimensions of work circumstances, compensation, and relationship with colleagues, professional growth, and the level of healthcare providers’ retention. In order to achieve the study goals, the researcher used the descriptive analytical approach. The researcher used the questionnaire as the study tool. The study population comprised all the healthcare providers at Turaif General Hospital. Questionnaires were distributed to the entire study sample that consisted of 220 individuals. The number of questionnaires valid for study was 183 questionnaires. The research findings were as follows: the participants’ estimate of the work circumstances dimension was high (3.64), the participants’ estimate of the compensation dimension was moderate (3.32), the participants’ estimate of the relationship with colleagues dimension was high (3.62), the participants’ estimate of the professional growth dimension was weak (2.39), and the participants’ estimate of healthcare providers’ retention level was intermediate (2.75). Accordingly, the researcher’s major recommendations are: the need to create the right atmosphere for personnel in hospitals, the interest of the hospital to provide the appropriate conditions for the staff in terms of the physical and moral aspects for building the work adjustment in the staff, and conducting training courses and educational lectures for personnel in hospitals on how to cope with the work pressures.

Background. In an effort to redistribute healthcare providersto underserved areas, many states have turned to financialincentive programs. Despite substantial research on theseprograms on a national scale, little is known about the successof such programs in Kansas. The purpose of this studywas to provide insight into the relationship between financial incentive programs and provider retention in Kansas.&#x0D; Methods. A cross-sectional telephone survey was conducted inApril and May of 2011 with participants who had completedtheir obligations to the Kansas State Loan Repayment Program(SLRP), the National Health Service Corps (NHSC) Loan Repaymentprogram, or the National Health Service Corps Scholar shipprogram in Kansas between January 2006 and January 2011.&#x0D; Results. Of the 112 providers included in the study, 54.4% (n = 61)had left their program sites sometime after finishing their commitment,with the mean length of stay after the obligation periodended being 7.3 (median = 3) months. Of the 54 participants whohad left their program sites and whose current locations wereknown, 33.3% (n = 18) were located in new Health ProfessionalShortage Areas (HPSA), 25.9% (n = 14) were in a new non-HPSA,and 40.7% (n = 22) had left the state. Family satisfaction with thecommunity and attending a professional school in Kansas wereassociated statistically with retention of physicians in Kansas.&#x0D; Conclusions. Nearly half of all participants had remained attheir sites even after their obligation period ended, with familysatisfaction with the community appearing to be the strongestpredictor for retention among those who had stayed.Efforts to match a provider’s family with the community successfullyand to support the family through networking mayimprove future provider retention. KS J Med 2016;9(1):6-11.

BackgroundInformation and communication technologies have become a vital infrastructural asset for use in the retention of rural health workers. However, little is known about the potential influence of ICT use, perceptions of health workers on ICT in healthcare delivery, and contribution of ICT to health care providers’ retention in rural and remote areas in rural post-war and conflict situations of northern Uganda.MethodsData from interviews were transcribed, coded and thematically analysed.ResultsParticipants generally exhibited low confidence, knowledge and low ICT skills. Majority of participants, however, perceived ICT as beneficial in relation to job performance and health care provider retention in rural areas. Common barriers for the implementation and use of ICT in health centres were inadequate ICT knowledge and skills, poor Internet networks, inadequate computers, inadequate power supply, lack of Internet Modems and expensive access to outside computer centres.ConclusionsThis qualitative study showed low confidence, poor knowledge and skills in ICT usage but positive perceptions about the benefits and contributions of ICT. These findings suggest the need for specific investment in ICT infrastructural development for health care providers in remote rural areas of northern Uganda.

BackgroundThis study describes job satisfaction and intention to stay on the job among primary health-care providers in countries with distinctly different human resources crises, Afghanistan and Malawi.MethodsUsing a cross-sectional design, we enrolled 87 health-care providers in 32 primary health-care facilities in Afghanistan and 360 providers in 10 regional hospitals in Malawi. The study questionnaire was used to assess job satisfaction, intention to stay on the job and five features of the workplace environment: resources, performance recognition, financial compensation, training opportunities and safety. Descriptive analyses, exploratory factor analyses for scale development, bivariate correlation analyses and bivariate and multiple linear regression analyses were conducted.ResultsThe multivariate model for Afghanistan, with demographic, background and work environment variables, explained 23.9% of variance in job satisfaction (F(9,73) = 5.08; P < 0.01). However, none of the work environment variables were significantly related to job satisfaction. The multivariate model for intention to stay for Afghanistan explained 23.6% of variance (F(8,74) = 4.10; P < 0.01). Those with high scores for recognition were more likely to have higher intention to stay (β = 0.328, P < 0.05). However, being paid an appropriate salary was negatively related to intent to stay (β = -0.326, P < 0.01). For Malawi, the overall model explained only 9.8% of variance in job satisfaction (F(8,332) = 4.19; P < 0.01) and 9.1% of variance in intention to stay (F(10,330) = 3.57; P < 0.01).ConclusionsThe construction of concepts of health-care worker satisfaction and intention to stay on the job are highly dependent on the local context. Although health-care workers in both Afghanistan and Malawi reported satisfaction with their jobs, the predictors of satisfaction, and the extent to which those predictors explained variations in job satisfaction and intention to stay on the job, differed substantially. These findings demonstrate the need for more detailed comparative human resources for health-care research, particularly regarding the relative importance of different determinants of job satisfaction and intention to stay in different contexts and the effectiveness of interventions designed to improve health-care worker performance and retention.

Improving maternal health and safety through adherence to postpartum hemorrhage protocol in Latin America

The Pediatric Nurse Practitioner Workforce: Meeting the Health Care Needs of Children

There is an ongoing shortage of rural healthcare providers relative to urban healthcare providers worldwide. Many strategies have been implemented to increase the distribution of rural healthcare providers, and financial incentives such as loan repayment programs have become popular means to both recruit and retain healthcare providers in rural communities. Studies detailing the effects of such programs on rural provider recruitment and retention are limited. The objective of this study was to assess the influence of loan repayment and other factors on the recruitment and retention of healthcare providers in rural Colorado, USA, and to compare the motivations and attitudes of these rural providers with their urban counterparts. A survey was sent to 122 healthcare providers who had participated in one of three loan repayment programs in Colorado between the years of 1992 and 2007: the Colorado Health Professional Loan Repayment Program; the Colorado Rural Outreach Program; and the Dental Loan Repayment Program of Colorado. Differentiation between rural and urban communities was accomplished by using the Rural Urban Commuting Area Codes developed by the University of Washington's Rural Health Research Center and Economic Research Service. Statistical analysis was performed using STATA from StataCorp. Of the 93 respondents included in the study, 57 worked in rural communities and 36 worked in urban communities during their programs. Of the rural participants, 74% were already working in or intending to work in an eligible community when they were made aware of the loan repayment program. Of those planning to work in a rural community regardless of any loan repayment option, 42% reported that the loan repayment program had an important influence on the specific community in which they chose to practice. Of the rural participants already working in a rural community, 38% reported loan repayment as being an important factor in their retention. The most important factors the rural providers cited for their recruitment were the location of the community, scope of practice, and family fit with the community. The most important factors for the urban providers were the location of the community, salary, and scope of practice. Of the rural providers, 36% attended rural high schools, while 9% of urban providers attended rural high schools. Of the rural providers who were planning on practicing in a rural area regardless of any loan repayment option, 37% had attended rural high schools. Rural participants most often left their communities because their families wanted to move, personal or professional isolation, and dissatisfaction with the medical community. Of rural participants 22% cited the desire for a higher income as an important reason to leave their communities, while the desire for a higher income was the most commonly cited reason for the urban providers. Rural retention rates were not influenced by past attendance at rural high schools or by intention to practice in a rural community regardless of loan repayment. Loan repayment programs targeting rural Colorado usually enroll providers who would have worked in a rural area regardless of loan repayment opportunities, but are likely to play a role in providers' choice of specific rural community for practice. They also appear to have a limited but important influence on rural provider retention, though financial concerns are generally less influential for non-retained rural providers than are family preferences and professional dissatisfaction.

Evaluation of rural clinical attachments has demonstrated that the rural setting provides a high-quality clinical learning environment that is of potential value to all medical students. Specifically, rural clinical education provides more 'hands on' experience for students in which they are exposed to a wide range of common health problems and develop a high level of clinical competence. Northern Ontario in Canada is a large rural region that has a chronic shortage of healthcare providers. The Northern Ontario School of Medicine (NOSM) was established with a social accountability mandate to contribute to improving the health of the people and communities of Northern Ontario, and is a joint initiative of Laurentian University, Sudbury, and Lakehead University, Thunder Bay, which are over 1000 km apart. The NOSM has developed a distinctive model of medical education known as distributed community engaged learning (DCEL), which weaves together various recent trends in medical education including case-based learning, community-based medical education, electronic distance education and rural-based medical education (including the preceptor model). The NOSM curriculum is grounded in Northern Ontario and relies heavily on electronic communications to support DCEL. In the classroom and in clinical settings, students explore cases from the perspective of doctors in Northern Ontario. In addition, DCEL involves community engagement through which communities actively participate in hosting students and contribute to their learning.This paper explores the conceptual and practical issues of community engagement, with specific focus on successful rural clinical education. Community engagement takes the notion of 'community' in health sciences education beyond being simply community based in that the community actively contributes to hosting the students and enhancing their learning experiences. This is consistent with the focus on social accountability in medical education. Implementing community engagement is quite challenging; however; its potential benefits are substantial and include the improved recruitment and retention of healthcare providers who are responsive to cultural diversity and community needs and are collaborating members of the whole health team.

Rates of preterm birth (PTB) and low birth weight (LBW) vary by region, with disparities particularly evident in the Appalachian region of the South. Community conditions related to rurality likely contribute to adverse birth outcomes in this region. This study examined associations between rurality and related community conditions, and newborn outcomes in southern Appalachia, and explored whether pregnancy smoking explained such associations. Data for all births in a southern Appalachian county over a 2-year period were extracted from hospital records. Data were available for 4,144 births, with 45 different counties of residence. Babies born to women from completely rural counties, on average, weighed 700 g less, were 1.5 inches shorter, and were born over 3 weeks earlier than less rural infants. In addition, these babies were 4.5 times more likely to be LBW, 4 times more likely to be PTB, and 5 times more likely to be admitted to the neonatal intensive care unit (NICU). Effects were also found for per capita income, poverty rate, and unemployment rate, all of which were associated with rurality. Some, but not all of the association was explained by elevated rates of pregnancy smoking. Babies born to women residing in rural and economically depressed counties in southern Appalachia are at substantially increased risk for poor birth outcomes. Improving these outcomes in the rural South will likely require addressing access to health services and information, health care provider retention, transportation services, employment opportunities, and availability of public health services including smoking cessation assistance.

Objectives. The objectives of this study were to: describe the length of employment of health care providers in rural Alaska; assess whether there are differences in length of employment among community health aides, medical doctors, and nurses; and determine whether provider length of employment is significantly increased following implementation of telemedicine.Study Design. We conducted a prospective cohort study of length of employment among health professionals in rural Alaska, and identified the cohort based on current employment status of community health aides, medical doctors, and nurses.Methods. Employment data were collected from four Alaska Native regional health corporations. Kaplan-Meier product-limit survival analysis was used to assess employment length. The Mantel-Haenszel log-rank test was used to test the difference between retention (survival) curves among doctors, nurses, and community health aides for all four regional health corporations combined. Data included provider hire date, termination date, and position title. Fifty seven percent of the data points were right-hand censored.Results. The community health aides (median (Mdn) = 1186 days) were retained significantly longer than either the doctors (Mdn = 596 days), or the nurses (Mdn = 408 days), who were not significantly different from each other (log-rank χ2 (2, N = 996) = 68.30, p = 0.0001).Conclusions. Our findings document that community health aides in the region retain their jobs significantly longer than doctors and nurses. Findings highlight the problem of providing an adequate health work force in rural areas.