International Journal of Health Care Quality Assurance ISSN: 0952-6862 Online from: 1988 Subject Area: Health Care Management/Healthcare Content: Latest Issue | Latest Issue RSS | Previous Issues Options: Add Table of Contents Alert | Add to Favourites EarlyCite Article Physician Recruitment and Retention in Rural and Underserved Areas Document Information: Title: Physician Recruitment and Retention in Rural and Underserved Areas Author(s): Dane Lee, (Texas Wesleyan University), Tommy Nichols, (Texas Wesleyan University) Citation: Dane Lee, Tommy Nichols, (2014) "Physician Recruitment and Retention in Rural and Underserved Areas", International Journal of Health Care Quality Assurance, Vol. 27 Iss: 7 Article type: Literature review Publisher: Emerald Group Publishing Limited Abstract: Purpose - The purpose of this paper is to identify the challenges of recruiting and retaining rural physicians and to ascertain certain methods that make rural physician recruitment and retention successful. There are studies that suggest "rural roots" is an important factor in recruiting rural physicians, while others look at rural health exposure in medical school curricula, self-actualization, sense of community, and spousal perspectives in the decision to practice rural medicine. Design/methodology/approach - An extensive review of the literature was performed using the databases Academic Search Complete, PubMed, and The Cochrane Collaboration. Key words used in the search were rural, rural health, community hospital(s), healthcare, physicians, recruitment, recruiting, retention, retaining, physician(s), and primary care physician(s). Inclusion criteria included peer-reviewed full-text articles written in the English language, articles published from 1997-present, and articles limited to North America (United States and Canada). Articles from foreign countries were excluded because of the unique differences in their respective healthcare systems. Findings - While there are numerous articles that call for special measures to recruit and retain physicians in rural areas, there is an overall dearth of research. This review has identified several articles that suggest recruitment and retention techniques. There is a need for a research agenda that includes valid, reliable, and rigorous analysis with formulation and implementation of these strategies. Originality/value - Rural Americans are under-represented when it comes to healthcare and what research there is to assist administrators with recruitment and retention is difficult to find. This paper identifies the relevant available research and highlights key strategies. Introduction Many physicians in the United States are reaching retirement age, and the new generations of physicians tend to have a different approach to medical practice, placing greater value on a worklife balance. The Office of the Inspector General has cited physician scarcitiesincluding specialties of obstetrics and family practice. These specialties are considered the \"backbone\" of rural medicine. It has been predicted that there will be a 20% physician shortage in the next two decades. This effect will be especially detrimental to rural hospitals. A rural hospital's ability to recruit and retain physicians affects its ability to deliver essential medical care to rural communities (Cohn and Harlow, 2009). Unlike its urban counterparts, rural hospitals have more unique challenges in recruiting and retaining physicians. In considering the unique challenges rural hospitals face, it has been estimated that 65% of rural US counties lack adequate numbers of health professionals, and the distribution of physicians favors urban areas. This fact creates a barrier to healthcare for residents in rural areas, as they must travel further to see a physician compared to urban residents. Recruitment and retention of rural physicians remains a challenge and this problem impacts access to healthcare for rural residents (MacDowell, Glasser, Fitts, Nielsen, and Hunsaker, 2010). The purpose of this paper is to identify the challenges of recruiting and retaining rural physicians and to ascertain certain methods that make rural physician recruitment and retention successful. There are studies that suggest \"rural roots\" is an important factor in recruiting rural physicians, while others look at rural health exposure in medical school curricula, selfactualization, sense of community, and spousal perspectives in the decision to practice rural medicine. Methods An extensive review of the literature was performed using the databases Academic Search Complete, PubMed, and The Cochrane Collaboration. Key words used in the search were rural, rural health, community hospital(s), healthcare, physicians, recruitment, recruiting, retention, retaining, physician(s), and primary care physician(s). Inclusion criteria included peer-reviewed full-text articles written in the English language, articles published from 1997-present, and articles limited to North America (United States and Canada). Articles from foreign countries were excluded because of the unique differences in their respective healthcare systems. This review of the literature is presented by topics revealed in the articles. 2 Rural Physician Recruitment Strategies Any healthcare organization's ability to recruit and retain physicians affects its ability to deliver critical healthcare needs to the communities they serve. Recruiting is difficult, due to increased demand of physicians from a limited pool. In addition, many healthcare organizations have difficult process requirements; a simple mistake in the process or a careless remark can drive potential candidates away (Cohn and Harlow, 2009). Recruitment strategies were identified to make the recruitment and retention of physicians successful. The first strategy is to get the Chief Executive Officer (CEO) involved in the role of physician recruitment. CEOs must do the following: a) develop a recruiting team, and meet with the team at least quarterly to monitor progress and offer guidance, b) participate in developing marketing and recruiting strategies and interview all promising candidates, c) financially support the recruiting team's recommended financial incentives for physicians, d) hold the recruiting team members accountable by tying their compensation and advancement in the organization to their recruiting performance, and e) request the recruiting team to brief candidates regarding abrasive personalities on the existing medical staff (Cohn and Harlow, 2009). The recruiting and marketing teams must come together to develop compelling marketing materials and programs. Physicians and employees are encouraged to notify the recruiting team of any pre-med students, medical students, or residents who are looking to return to their hometown to practice. Also, this request should be extended to physician's spouses as well. The hospital should sponsor a guest speaker and invite the community to the event. This effort promotes the facility as a good neighbor and great employer. Also, the benefits of working for the organization should be publicized. These benefits should include benefits of the community as wellfocus on the positives of the community (school systems, recreation, etc.) (Cohn and Harlow, 2009). Based on a community needs assessment that demonstrates a physician specialty shortage, organizations should offer appropriate financial incentives. These incentives include reimbursement of travel and moving expenses, assistance with legal fees associated with obtaining foreign physician work visas, student loan repayment or start-up costs for starting a practice, income guarantees for the first two years of practice in the community, and compensation for call requirements. Importantly, the recruitment team should consult an experienced healthcare attorney to ensure the legality of these compensation incentives (Cohn and Harlow, 2009). With an increased reliance on web-based technology, it is important that rural facilities familiarize themselves with web-based recruitment. Rural facilities must have a dedicated recruitment web page with links to other topics of interest. The website should have a direct contact with the facility's recruiter. Also, it is recommended that the website have the capability for online application. Some other features that would be helpful to a potential physician recruit are virtual tours and maps of the facility and testimonials from long-term physicians and their spouses. Social media, like Facebook, should also be considered (Cohn and Harlow, 2009). The interview process should be memorable, and the interview process must be prepared well in advance. There should be a core group of interviewers, including a physician with a similar background and training as the physician being interviewed. The interview should be scripted and structured, beginning and ending the process with the CEO, Chief Operating Officer (COO), or the Chief Medical Officer (CMO). The logistics of the visit should be planned so that 3 the interviewing physician is not burdened with the expenses of travelincluding hotels, restaurants, and car rental. These expenses should be billed directly to the facility. If applicable, the facility should offer a spouse or family an activity while the candidate attends the interview. A tour of the community and lunch with other physician spouses may provide useful for information and networking opportunities (Cohn and Harlow, 2009). The job offer must be carefully executed, and this begins with a verbal agreement. Once the verbal agreement has been accepted, the organization should execute a contract. Adding extra incentive beyond what the candidate expected creates a positive surprise that makes the physician feel valued and motivated. The contract should include an expiration date, usually one to two weeks. The facility's attorney should review all aspects of the contract, and that counsel should be involved in developing the contract in order to ensure compliance with all applicable laws and regulations (Cohn and Harlow, 2009) The recruiting team must screen candidates by conducting a thorough review of the applicant's education, experience, references, and credentials. There should be communication with the CEO and other stakeholders on a monthly basis. Acknowledgements should be sent to interested candidates within 48 hours of receipt of the candidate's resume. It is recommended that an organization use a checklist as a general guide to prepare a contract. The checklist should be modified to meet the facility's unique needs while conforming to current local, state, and federal regulations (Cohn and Harlow, 2009). Documentation is extremely important to comply with federal Stark and anti-kickback laws. The employment contract and all other recruitment-related materials must be supported by documentation. Because of the anti-kickback statute, state regulations, and Stark laws, the organization's ability to offer recruitment incentives is hampered by significant restrictions. To address these issues, documentation is required based on the community's need for the recruited physician's specialty, the physician's relocation to practice, reasonableness of recruitment bonus based on current fair-market value analysis, and leases on space and equipment (Cohn and Harlow, 2009). Facilities that enter into a forgivable loan agreement with the medical practice that recruited the physician are more favorable than an agreement with the physician directly. This is because if the recruited physician leaves the practice, the facility may be reimbursed for its expenses by the practice that recruited the physician (Cohn and Harlow, 2009). There are three main reasons for the unpopularity of rural physician practice: lifestyle issues, medical practice issues, and competitive issues. Lifestyle issues are prevalent because physicians are concerned about residing in a community that has limited access to a variety of social activities. The perception of rural practice has limited outlets to culture, social, and shopping activities. Also, school systems in these settings are thought to be subpar compared to urban systems (Full, 2001) Medical practice issues consist of longer hours and more demanding on-call schedules compared to urban colleagues. Medical care can be more challenging without the immediate availability of specialists. The payer mix is definitely on the downside, with 70% Medicare, Medicaid, or self-pay. In addition, reimbursement for physicians in rural areas is less. The population in rural settings is usually older, poorer, more likely to be uninsured, and in poorer health overall (Full, 2001). Primary care physicians (PCPs) are in great demand. Rural opportunities are often missed because rural hospitals' urban competitors have residency programs that \"lock\" in physicians before potential recruits are aware of rural opportunities. In addition, larger facilities are often 4 better suited to offer employment opportunities that rural facilities cannot because of a fundamental lack of resources (Full, 2001). A CEO from a small, critical access hospital in northeast Indiana outlined recruiting strategies for rural hospitals. This particular hospital is the sole hospital provider for a rural county of approximately 27,000 people. This hospital is not-for-profit, county-owned, and a stand-alone rural health system. The hospital had a reputation for having a dysfunctional medical staff that was perceived by community members as providing poor medical care. Over 80% of residents traveled more than 30 miles for healthcare. At the time of his appointment as the CEO, there was a physician shortage that had an adverse effect on the hospital's financial status and future survival (Full, 2001). This particular CEO was the third appointed to this facility in a five year period. When he arrived, 85% of the county residents traveled elsewhere for medical care. Two physicians accounted for 90% of all admissions to the hospital. The hospital was in financial distress and operated in the red. He reflected on his strategy to turn this small, critical access hospital around. His main strategy was to recruit a quality medical staff in a four step process called \"plan, locate, screen, and sell\" (Full, 2001). In the planning phase, a great deal of emphasis was placed on the education of the board of trustees, medical staff, employees, and community leaders regarding the future trends in healthcare. The \"planning\" process was accomplished through strategic planning retreats, medical staff meeting discussions, and community leader presentations. The first day of the retreat consisted of extensive brainstorming sessions and discussions regarding the strengths and weaknesses of the existing medical staff. During this retreat, the board of trustees identified two physicians the hospital would center around to re-build a quality medical staff. Based on a needs analysis of one physician to every 2,000 to 4,000 members of the community, the board determined that seven additional PCPs would be required to meet the needs of their community. This goal was incorporated into the hospital's five-year strategic plan. Later, the two core existing PCPs were brought into the plan with supportive enthusiasm. The initial planning consisted of updating medical equipment and giving patient care areas a facelift (Full, 2001). The locating process included utilizing physician search firms, both retainer and contingency, to extensively locate potential physician candidates. Importantly, the retainer firm, which works exclusively for the hospital but requires a significant monetary deposit, was unsuccessful. Alternatively, the contingency firm, which is paid if one of their recruits signs a contract, proved to be much more effective. Generally, a contingency firm is paid $15,000 to $22,000 when a hospital and a physician come to contractual terms (Full, 2001). This particular hospital signed agreements with 16 contingency firms, and roughly seven of those worked routinely with the hospital. The CEO noted that developing a positive rapport with these firms helped in the cause to develop a win-win relationship. The CEO screened an abundant number of candidates over the years once a positive rapport was developed (Full, 2001). Another avenue identified to identify potential candidates was the National Health Service Corps. After the hospital was identified as a \"health professional shortage area,\" the CEO requested that the Indiana State Board of Health initiate a study to determine if the hospital was indeed in a shortage area. The results were favorable, and the State recommended to the federal government that the county be designated as a health professional shortage area. This designation has many benefits (Full, 2001). Physicians who practice in such an area are available for federal loan waivers, and National Health Service Corps physicians are required to practice in such an 5 area with this designation. Further, PCPs receive a 10% quarterly bonus from Medicare for practicing in a shortage area, and many PCPs review and respond to such governmental incentives that have access to student loan waivers. The screening process ensues once potential physicians are identified. Once a National Practitioner Databank inquiry is made, and no problems are identified, a personal inquiry of the physician's curriculum vitae is made to determine if the physician \"job-hops.\" If this is the case, the physician is ruled out. A telephone interview with the physician candidate is then initiated to assess communication skills, longevity potential, sense of community, professional interests, spouse's career needs (if applicable), academic concerns for their children (if applicable), and professional requirements (hospital employment versus private practice). If the initial interview is positive, the physician and his or her spouse are invited for an on-site second interview (Full, 2001). If the physician is a fit for the facility and the community, then it is time for the \"sell.\" The CEO dedicates 100% of his time to the candidate and his or her family. Accordingly, this is considered the most important event during the entire recruitment process. To lessen the burden on the physician, all travel arrangements are made by the hospital. A fruit basket and flowers are sent to the hotel room, and the first meeting is over breakfast. After breakfast, a tour of the facility is given followed by a tour of the community. Key stops are made to meet the school superintendent and a tour of the local businesses to meet community leaders. Active listening to the needs of the physician and his or her spouse is paramount. At this point, the CEO reinforces the strengths of the community (Full, 2001). Adjustments have been made in recruiting strategies to meet the needs of the candidates. One major change has involved the provision of the hospital employing the physician. The employment arrangement usually consists of a salary with an incentive program. For those physicians who prefer private practice, an income guarantee is provided for a set number of years in order for the physician to build a patient base. School debt is a major concern for many candidates. This is addressed by the Federal Loan Waiver option. Also, committed first-year residents are offered a monthly stipend during residency, and the resident in turn makes a five year commitment to practice in the community after completing the residency program (Full, 2001). This CEO's \"plan, locate, screen, and sell\" philosophy has paid the hospital great dividends. During his tenure the hospital's CEO has successfully recruited and retained seven PCPs, a general internist, the areas first OB/GYN and pediatrician, an anesthesiologist, and an invasive radiologist. With one exception, the oldest physician at the facility is 46 years old. Five of the physicians are employed by the hospital, and the hospital also recruited four family nurse practitioners. Despite the initial cash drain that bringing on new physicians caused, the hospital's gross revenues have increased by 19% per year. Also, the hospital went from employing 75 people in 1992, to 230 employees at the time the article was published (Full, 2001). The Roles of Medical Education and \"Rural Roots\" Sustainable levels of rural healthcare have been a challenge because rural communities suffer from a shortage of PCPs. Rural populations tend to be older, poorer, less educated, and perceived as having a lower level of health compared to urban residents. This notion is compounded by the fact that recruiting and retaining rural physicians is particularly troublesome. Numerous factors have been identified and include having partners in practice, family concerns and recreation, and burdensome call schedules. Other deterrents to rural practice include low reimbursement for fee 6 for service and low-volume emergency rooms. Physicians in rural settings are required to perform more procedures than their urban colleagues, and this higher level of responsibility can place an enormous level of stress on rural physicians, especially in emergency situations (Curran and Rourke, 2004) Medical education plays an important role in the recruitment of rural physicians. The location, mission, and organization of medical schools have shown some predictability of physicians choosing rural practice. Medical schools that are decentralized, located in rural areas, have a curriculum with a rural focus, and provide early and repeated exposure to rural learning experiences are most successful in graduating physicians who choose to practice in rural areas (Curran and Rourke, 2004; Spencer and Spencer, 2006). There are some medical schools in large cities that have developed specific curricula for educating physicians for rural areas (Rourke, 2010). Outreach strategies employed by medical schools to selectively retain seats for rural medical school applicants enhance PCP career choice of physicians entering practice serving rural areas (Curran and Rourke, 2004). Students from rural areas in most countries are underrepresented in medical schools, and students from rural areas should expect to have fair opportunities to attend medical school (Rourke, 2010). Studies have shown that medical students with rural backgrounds are more than four times likely to practice rural medicine than their urban colleagues, and this remains the strongest predictor of rural practice choice (Curran and Rourke, 2004; Hancock, Steinback, Nesbitt, Adler, and Auerswald, 2009). A study was conducted with a study population of 3414 physicians who graduated from Jefferson Medical College's Physician Shortage Area Program from 1978 to 1993 (Curran and Rourke, 2004). The purpose of the study was to identify medical student applicants who would eventually return to rural areas to practice family medicine in Pennsylvania. A number of seats were reserved for qualified applicants that had grown up, lived, or had strong ties to a physician shortage area. The authors found that graduates with a rural background and freshman-year plans to practice family medicine were more than twice as likely to practice as a PCP in rural areas. The authors suggest that the greatest success for recruiting rural PCPs is for medical schools to develop strategies to increase rural applicants with plans to practice family medicine. Hancock et al. (2009) propose that a predictor of rural practice is exposure to rural medicine by providing opportunities for students to choose rural electives in medical school. The authors suggest that rural electives appear to have a greater influence to practice rural medicine for those students raised in urban areas. A survey was conducted in Canada to examine the influence of rural medical education on the decision to practice rural medicine. Questions were broad and included: how large was the community in which you lived in high school; rate your level of interest in rural family practice at different stages of your training; how much of a positive interest did rural training, financial incentives, past exposure to rural areas impact your decision for rural practice? Respondents were asked to rank these factors in order of importance. Respondents were located from the Southam Medical Databasea commercial database widely used in Canada (Chan, Degani, and Crichton, 2005). There were 784 physicians surveyed though some were ineligible due to demographics, providing a response rate of 59%. One-third of respondents grew up in communities of less than 10,000 people, while the remainder grew up in varying size urban communities. It was noted that rural physicians showed an increase in rural medicine as they progressed through school. At the start of medical school, only 28% were certain they wanted to practice rural medicine. At graduation, this number rose to 77%. At the beginning of medical school, students with a rural background were more likely than those with an urban upbringing to show an interest in rural 7 medical practice, 90% versus 67%, respectively. At graduation, this gap narrowed, but it still remained significant (98% versus 91%, P < .0001) (Chan et al., 2005). In this study, the two main factors predicting rural medicine practice for physicians with both rural and urban backgrounds were the challenge of rural medicine and enjoyment of a rural lifestyle. Rural residents cited growing up in rural settings as the most important factor in choosing to practice rural medicine, and urban residents indicated that it was their exposure to rural practice during medical school or residency that influenced their decision to engage in rural practice. Physicians raised in urban areas would have difficulty appreciating the aspects of rural practice without exposure to rural settings in their medical school curriculum. The authors conclude that rural education during medical school has a significantly greater influence to choose rural practice on physicians raised in urban areas than on physicians raised in rural areas. In fact, physicians with an urban upbringing constitute the main source for rural PCPs, accounting for two-thirds of new rural physicians (Chan et al., 2005). There are successful initiatives for changing the perceptions of rural practices. There are four models of medical educational programs that have shown success in attracting medical students to rural primary care. In New York, the Continuity Care Program is affiliated with the State University of New York. Medical students spend the first two years at Syracuse, and each third-year student in the Continuity Care Program spends half a day with a rural PCP. Another program uses the Physician Shortage Area Program of Jefferson Medical College in Philadelphia to focus on selective admission policies for rural students. This program reserves 24 of the 223 slots in each class for students who intend on practicing rural family medicine. Another program from the State University of New York is the Extended Rural Preceptor program. In this program a number of third-year medical students are placed in rural areas to work full-time for nine months under the supervision of PCPs or specialists. When the students live and work in these rural areas, they gain an appreciation of rural community life. The Michigan Upper Peninsula program is similar to the Extended Rural Preceptor Program. These students come to understand and appreciate rural healthcare and the people in the community (Perch, Yallpragada, Birkenmeier, Authement, and Roe, 1997). There are also opportunities for foreign physicians. A law passed in 1976 requires that graduating foreign physicians return to their country for a period of two years before applying for a permanent US visa. However this requirement can be waived if the foreign physician agrees to practice in a rural, medically underserved area (Perch et al., 1997). Self-actualization, Sense of Place, and Community Engagement It has been identified that 67% of rural areas qualify as Health Professions Shortage Areas (HPSAs), and the most rural areas are the ones most underserved (Hancock et al., 2009). Challenges with recruitment and retention continue to be a major problem in these areas. Fewer than 4% of graduating medical students plan to practice in small towns, a percentage that has been decreasing over the past 30 years. (Hancock, et al., 2009). There is little research examining the retention of rural physicians. It has been suggested, however, that the role of the community is important in the retention of rural physicians, and the factors that recruit the physician to the area are not the same factors that retain them. The broader scope of the community has an impact on retention, specifically in terms of location and support (Cameron, Este, and Worthington, 2012). Even though rural physician retention is assumed to be poor, relevant studies reveal that rural physician retention is actually comparable to urban retention. Efforts at rural physician retention are increasing to offset the challenges of recruiting them in the first place. There is consistent evidence that practice-related and lifestyle factors play 8 much more of a role in rural physician retention than other factors such as rural roots, training, and community service. These factors consist of compatibility with the medical community or parenting a minor-aged child. Previous studies have downplayed the physician's environment, instead emphasizing physicians' personal characteristics. Two concepts overlooked are \"sense of place\" and \"self-actualization\" (Hancock et al., 2009). A sense of place describes the emotional ties a person has with their community, providing identity, roots, and attachment (Hancock et al., 2009). In addition to striving for a sense of community and place, individuals are motivated to lead happy and fulfilling lives. As described by Maslow's Hierarchy of Needs, this is phrased self-actualization. These concepts provide an applicable framework for administrators, policy makers, and other stakeholders to understand other motivations for physicians (Hancock et al., 2009). A semi-structured interview and questionnaire was administered to 22 committed PCPs in rural northeastern California and northwestern Nevada during June and July of 2006 and 2007. The interviewees were considered representative of the sample of rural PCPs in terms of gender, medical education, and specialty. This study began as an investigation of the effect of rural exposure on rural recruitment and retention. Seven of the 22 respondents stated they chose rural practice because of a desire to live in a familiar, natural or social environment. This gave them a sense of trust, comfort and ease. Nine of the 22 respondents cited a sense of community as one of their primary motivations for choosing rural practice. Six of the 22 respondents stated their decision was based on a sense of place, and finally, seven respondents chose rural practice primarily because they could lead happy and successful personal and professional lives (selfactualization) (Hancock et al., 2009). The concept of self-actualization emerged as motivations for rural practice. These findings support the need for comprehensive mentorship and development programs for new rural physicians. These programs should be a policy and funding priority with regard to physicians entering rural primary practice (Hancock et al., 2009). Spousal Perspectives Mayo and Matthews (2006) report that are many studies that support the critical role physician's spouses play in the decisions to practice and remain in rural areas. In their study, the researchers use qualitative informant interviews to examine the experiences and perspectives of spouses of rural physicians in order to gain a better understanding of the spouse's satisfaction of rural living. The study participants were from rural Canada. Of the twenty-three physicians in the region, fifteen met the inclusion criteria, and thirteen of the spouses agreed to the interview (Mayo and Matthews, 2006). From the interviews, the authors identified a number of contentment and perception factors of rural living. These factors were organized into two themes: direct and indirect factors. The direct factors have more of an immediate influence on contentment. Content spouses and their children are more likely to stay in the rural area. The two direct factors identified with spousal contentment with a rural practice were physician workload and community integration. The authors found that children influence contentment with a rural community, and physicians with young children were more prepared to stay in the rural community than those without children (Mayo and Matthews, 2006). The authors also found indirect factors regarding spousal contentment. These indirect factors were licensing requirements, the number of physicians in the community, remuneration, and community characteristics. Importantly, the number of physicians in the community affects 9 the physician's workload. The more physicians, the more available time off the physician has with his or her family. Interestingly, income was not a primary consideration for rural practice. For those who were content, remuneration in itself did not affect their decision to stay in the rural community (Mayo and Matthews, 2006). The Cochrane Collaboration The Cochrane Collaboration conducted a study to assess the effectiveness of interventions focused on increasing the proportion of health professionals working in rural and other medically underserved areas. Databases searched included the specialized register of the Cochrane Effective Practice and Organisation of Care Group (up to July 2007), the Cochrane Central Register of Controlled Trials and the Database of Abstracts of Reviews of Effectiveness (up to July 2007), MEDLINE (1966 to July 2007), EMBASE (1988 to July 2007), CINAHL (1982 to July 2007) and LILACS (up to July 2007). The authors also searched the reference lists of all papers and relevant reviews identified. Also, authors of relevant articles were contacted regarding any further published or unpublished work. The selection criteria included randomized controlled trials, controlled trials, controlled before-after studies and interrupted time series studies that evaluated the effects of the various popular interventions including educational, financial, or regulatory strategies on the recruitment and/or retention of health professionals in medically underserved areas. A total of 1844 studies and abstracts were reviewed, and no studies met the inclusion criteria (Grobler, Marais, Mabunda, Marinidi, Reuter, and Volmink, 2009). According to Grobler et al. (2009), 9% of registered physicians in the United States practice in rural areas where 20% of the population resides. Based on the common interventions to recruit and retain physicians to rural areas, the authors of this study felt it was important for stakeholders and policymakers to be aware of the scientific evidence that supports the effectiveness and impact of the interventions outlined in previous studies. The objective of this study was to assess the interventions used to recruit and retain physicians working in rural, medically underserved areas (Grobler et al., 2009). The authors grouped the interventions or strategies for rural physician recruitment and retention into four categories: educational, financial, regulatory, and supportive. Educational interventions included student selection criteria, teaching curricula, and exposure to rural and underserved areas. Financial interventions included scholarships linked to future practice location, rural allowances, and increased salaries. Regulatory strategies included compulsory community service and relaxed work regulations imposed on foreign medical graduates who are willing to work in rural underserved areas. Support strategies consisted of providing adequate professional support and attending to the needs of the practitioner's family (Grobler et al., 2009). The main finding of this study is that there are no well-designed studies in which bias and confounding are minimized to address the shortage of rural physicians. The findings of existing studies are mainly observational, and the impacts of the strategies employed are poorly quantified. Despite the lack of reliable evidence, these strategies have been implemented to address the shortage of physicians in rural areas. The authors suggest rigorous evaluations of the strategies to recruit and retain physicians to rural medically underserved areas to determine the future impact of these interventions and to better educate and direct future policy (Grobler et al., 2009). Conclusion 10 It is well-known that rural Americans are under-represented when it comes to healthcare. There are numerous articles that call for special measures to recruit and retain physicians in rural areas, though there is an overall dearth of research. Some authors have outlined the importance of the \"rural roots\" of the physician to return to rural practice. Others argue that early and repeated exposure to rural medicine in the medical school curriculum is key to bringing in rural physicians. Also, there is the human dynamic where spousal perspectives and raising young children always plays a role in practice location. Financial incentives, such as loan forgiveness, have been identified, but there has not been much emphasis on remuneration as a factor in retention efforts. Finally, while some of these recruitment and retention strategies represented in these articles hold promise, the Cochrane Review found no well-designed studies to determine, with scientific evidence, that any of these strategies are efficacious for recruiting and retaining rural physicians. This review has identified several articles that suggest recruitment and retention techniques. There is a need for a research agenda that includes valid, reliable, and rigorous analysis with formulation and implementation of these strategies. With these techniques in place, perhaps rural Americans will have better access to healthcare because more physicians will gravitate to rural medically underserved areas. References Cameron, P., Este, D., and Worthington, C. (2012), 'Professional, personal and community: Three domains of physician retention in rural communities', Canadian Journal of Rural Medicine, Vol. 17 No. 2, pp. 47-55. Chan, B., Degani, N., Crichton, T., Pong, R., Rourke, J., Goertzen, J., and McCready, B. (2005), 'Factors influencing family physicians to enter rural practice: Does rural or urban background make a difference?', Canadian Family Physician, Vol. 51 No. 12, p. 1247. Cohn, K., and Harlow, D. (2009), 'Field-tested strategies for physician recruitment and contracting', Journal of Healthcare Management, Vol.54 No. 3, pp. 151-158. Curran, V. and Rourke, J. (2004), 'The role of medical education in the recruitment and retention of rural physicians', Medical Teacher, Vol. 26 No. 3, pp. 265-272. Full, J. M. (2001), 'Physician recruitment strategies for a rural hospital', Journal of Healthcare Management, Vol. 46 No. 4, p. 277-282. Grobler, L., Marais, B.J., Mabunda, S.A., Marindi, P.N., Reuter, H., and Volmink, J. (2009), 'Interventions for increasing the proportion of health professionals practising in rural and other underserved areas' Cochrane Database of Systematic Reviews, Vol. 1. No. 2, pp. 125. Hancock, C., Steinbach, A., Nesbitt, T.S., Adler, S.R., and Auerswald, C.L. (2009), 'Why doctors choose small towns: A developmental model of rural physician recruitment and retention', Social Science Medicine, Vol. 69 No. 9, pp. 1368-1376. MacDowell, M., Glasser, M., Fitts, M., Nielsen, K., and Hunsaker, M. (2010), 'A national view of rural health workforce issues in the USA', Rural Remote Health, Vol. 10 No. 3, pp.112. Mayo, E. and Mathews, M. (2006), 'Spousal perspectives on factors influencing recruitment and retention of rural family physicians', Canadian Journal of Rural Medicine, Vol. 11 No. 4, pp. 271-276. Perch, A., Yallapragada, R.R., Birkenmeier, B., Authement, J.P., and Roe, C.W. (1997), 'Recruitment of primary healthcare physicians in rural areas', Hospital Topics, Vol. 75 No. 4, p. 29-33. 11 Rourke, J. (2010), 'How can medical schools contribute to the education, recruitment and retention of rural physicians in their region?' Bulletin of the World Health Organization, Vol. 88 No. 5, pp. 395-396. Spencer, A. and Spencer, S. (2006), 'It takes more than rural roots to make a rural doc', Canadian Journal of Rural Medicine, Vol. 11 No. 2, pp. 129-130. 12 Outline I (Your Name) Characteristic Focus Goal Perspective Coverage Organization Audience Categories Research outcomes Research methods Theories Practices or applications Integration (a) Generalization (b) Conflict resolution (c) Linguistic bridge-building Criticism Identification of central issues Neutral representation Espousal of position Exhaustive Exhaustive with selective citation Representative Central or pivotal Historical Conceptual Methodological Specialized scholars General scholars Practitioners or policymakers General public Similar to the trust a patient has in their physician, a healthcare organization's employees, patients and stakeholders must have trust in its' leadership. Healthcare leaders drive an organization's mission and manage an institution's resources. Therefore, a culture of trust must be a component of an organization for it to succeed both internally and externally. The purpose of this literature review will be to discuss the important variables a leader must cultivate in order to create a culture of trust. Based on the existing body of literature this will be a qualitative review. I. II. III. IV. Introduction Definition of a culture of trust. Focus of the review. a. Inclusion criteria. Methods and behaviors that create internal and external trust. b. Exclusion criteria. Events outside of healthcare (Politics and world events) that impact trust Identification of essential themes. V. VI. VII. Creation of the hypothesis[ CITATION Pix08 \\l 1033 ][ CITATION Ser09 \\l 1033 ][ CITATION Rog \\l 1033 ] Summary Conclusion Bibliography Ciancutti, A. R., & Steding, T. L. Built on Trust: Gaining Competitive Advantage in any Organization. Chicago, IL: Contemporary Books. Covey, S. M., & Covey, S. R. (2006). The Speed of Trust: the One Thing That Changes Everything. New York, NY: Simon & Schuster . Pixton, P. (2008). Creating a Culture of Trust. Accelinnova.com. Rogers, R., & Riddle, S. (n.d.). Trust in the Workplace. 2009: DDI Competitive Advantage Realized. Serrat, O. (2009, August). Building Trust in the Workplace. Knowledge Solutions. Shore, D. A. (2006). The Trust Crisis in Healthcare. New York, NY, USA: Oxford University Press. Shore, D. A. (2005). The Trust Prescription for Healthcare. Chicago, IL: Health Administration Press Literature Review Outline II (Your Name) Nursing Stress and Burnout Characteristic Categories Focus Research outcomes Research methods Theories Practices or applications Goal Integration (a) Generalization (b) Conflict resolution (c) Linguistic bridge-building Criticism Identification of central issues Perspective Neutral representation Espousal of position Coverage Exhaustive Exhaustive with selective citation Representative Central or pivotal Organization Historical Conceptual Methodological Audience Specialized scholars General scholars Practitioners or policymakers General public Introduction o The NIOSH report on the right is an excellent resource that cites the following: 40% of workers reported their job was very or extremely stressful; 25% view their jobs as the number one stressor in their lives; Three fourths of employees believe that workers have more on-the-job stress than a generation ago; 29% of workers felt quite a bit or extremely stressed at work; 26 percent of workers said they were "often or very often burned out or stressed by their work" Job stress is more strongly associated with health complaints than financial or family problem o Because of the widespread damage stress can cause, it's important to know your own limit. But just how much stress is \"too much\" differs from person to person. Some people roll with the punches, while others crumble at the slightest obstacle or frustration. Some people even seem to thrive on the excitement and challenge of a high-stress lifestyle. o Research has shown that there are three critical factors promoting negative stress in the work environment. The first deals with employees' lack of confidence in their ability to deal with work demands. The second concerns lack of personal control, for example, one can't exert influence over tasks during a normal working day (Karasek 1979). The third factor concerns social sup- port, for example, employees' feelings of exclusion from the group and their lack of confidence in coworkers. Another aspect of low support is that competence and experience are not noticed and respected, as shown through support and feedback from supervisors (Cohen & Wills 1985).Absence of response: a study of nurses experience of stress in the workplace o Stress and Burnout in Nurse Anesthesia You may be more prone to burnout if*: You identify so strongly with work that you lack a reasonable balance between work and your personal life. You try to be everything to everyone. Your job is monotonous The first 2 are characteristic of the typical alpha individual drawn to our profession. As the stressful routine becomes the norm, burnout becomes a likely consequence Of the CRNAs responding, 40% were male and 60% females. Associate members had a higher response rate for females, at 70% Of the individuals who were CRNAs, the educators were the most stressed, with an average daily stress score of 6.15 and 90% of that stress from their jobs. When asked about how they handle stress, 31% of the members and 27% of the associate members indicated they had sought professional help for their stress. Of the CRNAs, educators have a higher degree of stress than others, with most of their stress coming from their jobs. They are second only to the associate members (students), who likewise have a higher degree of stress coming from their learning environment. Staff CRNAs have the lowest degree of stress. o Define Stress and Symptoms Stress is a normal physical response to events that make you feel threatened or upset your balance in some way. When you sense danger - whether it's real or imagined - the body's defenses kick into high gear in a rapid, automatic process known as the \"fight-or-flight\" reaction, or the stress response. The stress response is the body's way of protecting you. When working properly, it helps you stay focused, energetic, and alert. In emergency situations, stress can save your life - giving you extra strength to defend yourself, for example, or spurring you to slam on the brakes to avoid an accident. The stress response also helps you rise to meet challenges. Stress is what keeps you on your toes during a presentation at work, sharpens your concentration when you're attempting the game-winning free throw, or drives you to study for an exam when you'd rather be watching TV. It has long been observed that nurses are at a high risk of burnout (Maslach 1982). To date, nursing burnout as been related to high workload, age, gender, education level, length of experience in nursing profession, and personal characteristics such as hardiness, coping strategies and social support (Maslach 1982, Cameron 19940) o Acute The most common symptoms of acute stress include the following; emotional distress, manifested as anger, irritability, or depression; muscular problems, including tension headache, hack pain, and jaw pain; stomach, gut, and bowel problems; and physical symptoms such as elevated blood pressure, rapid heartbeat, sweaty palms, heart palpitations, dizziness, migraine headaches, cold hands or feet, shortness of breath, and chest pain.'' o Chronic Long-term exposure to stress can lead to serious health problems. Chronic stress disrupts nearly every system in your body. It can raise blood pressure, suppress the immune system, increase the risk of heart attack and stroke, contribute to infertility, and speed up the aging process. Long-term stress can even rewire the brain, leaving you more vulnerable to anxiety and depression Method of Research o EBSCOhost CINAHLplus: Nursing and Allied Health Literature MEDLINE: (PubMed) o Search terms: Nurse, Stress, Burnout, and Manager - nine results o Search terms: Nurse, Stress, Burnout - 331 Identify Themes of Findings o o o o o Education Age Workload Support Control Education o Job stress, achievement motivation and occupational burnout among male nurse Wong et al. (2001) noted that nurses with tertiary education have more positive thinking skills, and self confidence and commitment, all of which would help them handle occupational stress better than nurses with a secondary education. o Understanding Nurses' psychosomatic complications The majority of the participants made reference to the dissonance between their initial image of nursing when entering the nursing profession and the actual reality they experienced in their daily nursing practice. The first one relates to the dissonance between nurses' role expectations at the commencement of their career and the organizational and cultural restrictions of their practice reality that inhibit the fulfillment of these initial role expectations. o When does nursing Burnout begin? The study indicates that a significant proportion of nursing graduates reach the end of their university training in a dangerously fatigued state. This then raises the question of how nursing graduates can reasonably be expected to recover from this state as they progress into the environment of even more demanding and enduring stress during the GNP year, immediately after the completion of the BN course Age o Relationship between assertiveness and burnout among nurse managers It has been demonstrated that nurses are more prone to burnout the lower their age (Suzuki et al., 2003; Washimi & Nagae, 1998; Williams, 1989) and the shorter their nursing experience (Suzuki et al., 2003; Tao & Kubo, 1996). Tao and Kubo (1996) reported a critical point in age and years of experience, and nurses are less likely to burnout when exceeding the critical point at age 40 or 11 years of experience, although this could be interpreted that only those who survived burnout were remaining o Burnout among hospital nurses in China Age, years of experience, working position and professional title were significantly positively related to Emotional Exhaustion and were negatively related to Personal Accomplishment. Nurses who were married, senior and had higher professional titles experienced significantly higher levels of Emotional Exhaustion. Nurses aged 31-35 had the highest scores in Emotional Exhaustion, which were significantly higher than age group 21-25 (P = 0.001). Single nurses' Emotional Exhaustion score was significantly lower than the marriedgroup (P = 0.014). The manager groups' Emotional Exhaustion score was significantly higher than the nurse group (P = 0.003). The results of this study showed that younger nurses with less work experience, lower professional titles and lower working positions experienced lower levels of Emotional Exhaustion. This finding was supported by Foster (2003). However, this finding differs from Maslach and Jacksons (1996), who found that older nurses in the United States experienced a lower level of burn- out in Emotional Exhaustion, Depersonalization and reduced Personal Accomplishment than younger nurses. The findings of this research showed that younger nurses experienced lower levels of Personal Accomplishment. Another possible reason why older nurses with a greater experience and a higher professional title in nursing experienced higher levels of personal accomplishment could be related to what they have achieved in their lives. They may have achieved a good position, a higher professional title as they gained experience, and they may have had a greater opportunity to start (or have started) a family. o Contrasting burnout, turnover intention,... Generation X nurses experience more symptoms of job burnout and are more inclined to change their jobs than their colleagues of the Baby Boomer generation. The Generation X nurses reported a clearly more negative evaluation of value congruence, control and personal knowledge sharing involvement. In conclusion, the research reported here demonstrated that Generation X nurses experience their work settings as less consistent with their personal values than do nurses from the Baby Boomer generation. They also display more indicators of job burnout and less inclination to participate in knowledge sharing. o When does nursing burnout begin? Several studies have noted younger nurses showing a greater tendency towards burnout (or maladaptive chronic fatigue states) than older nurses (Bartz & Maloney 1986, Beierholm et al. 1989, Lee & Wang 2002, Bernardi et al. 2005, Winwood et al. 2006b). The study indicates that a significant proportion of nursing graduates reach the end of their university training in a dangerously fatigued state. This then raises the question of how nursing graduates can reasonably be expected to recover from this state as they progress into the environment of even more demanding and enduring stress during the GNP year, immediately after the completion of the BN course. Relatively inexperienced, newly graduated, nurses also commonly experience significant anxieties about clinical competency and role ambiguity (Healy & McKay 2000, Chang & Hancock 2003) o Burnout and the Med-Surg Nurse One study (Erickson & Grove, 2008) found a higher number of nurses experiencing burnout while still under the age of 30. \"Registered nurses under age 30 reported experiencing significantly higher rates of the most intense levels of frustration, anger, and irritation...than those over 30\" (Erickson & Grove, 2008, p. 8). It could be posited that burnout is higher in this age group of nurses because they continue to retain the ideals and techniques developed in nursing school, although it can also be posited that more experienced nurses have developed emotion management techniques that help defray the frustration felt by the younger, lessexperienced nurse. o Work-related fatigue and recovery The youngest age group reported the highest fatigue and poorest recovery compared to the oldest group, who reported the best characteristics. However, this latter group may represent a particularly well adapted 'survivor cohort'. The relationship between age and fatigue was partly confounded by older, experienced, nurses with greater job responsibilities, working fewer multiple shifts including night duty. In general, increasing age was not associated with poorer recovery or higher maladaptive fatigue. We had expected that age would be correlated with increased fatigue and poorer recovery between shifts. Instead, we found that the oldest age group in the study sample (55 years) reported the least chronic fatigue and acute fatigue and best recovery. The better recovery and lower fatigue among the oldest age group may also be explained by them forming a 'survivor cohort' which is particularly well adapted to the nursing profession, and in addition manifesting 'healthy worker' attributes (Sterling & Weinkam 1985, Portela et al. 2004). By comparison, those in the youngest age group (18- 24 years) reported the highest chronic fatigue and acute fatigue scores and the lowest recovery. The poor results of this group are consistent with reports that nurses face significant challenges in the first years after graduation in adapting to the work demands of nursing whilst overcoming inexperience and developing practical nursing and life skills, including time management (McNeese-Smith & van Servellen 2000, McNeese-Smith 2000). Workload o Nursing specialty and burnout Nurse practitioners often enter the field because they desire greater autonomy Emergency nurses often deal with an overload of patients and nurse managers must often negotiate the concerns of staff and management, nurse practitioners may be able to concentrate more fully on patient care. Opportunities to spend additional time with patients may help reduce work- related stressors, increase control, and ultimately decrease burnout. o Working Conditions, psychosocial resources and works stress Tennant (2001) claims that work stress is of increasing importance due to continuing changes in the workplace, with both increasing job demands and job insecurity imposed on employees. Karasek and Theorell (1990) found psychosocial job demands along with time pressure and conflicts to be significant sources of risk for stress-related illness. Job demands reflect the determined aspects of work, such as deadlines, challenges and expected performance. Other components included are stresses arising from personal conflicts that may have been caused by role conflict and task pressure (Karasek & Theorell 1990). It was found in both the manager groups that those who reported high job demands had more than six times higher probability for high work stress than those who were not in this situation. This study revealed that nurse managers and clinical directors who were exposed to high job demands had a significantly higher probability of high level of work stress than those who were not in this situation. The result also indicated that those who were exposed to high job demands had an increased risk of high level of work stress irrespective of available support taken together inside and outside work. o Job stress, achievement motivation and occupational burnout among male nurse Our study showed that job loading was the main source of job stress. o Absence of response: a study of nurses experience of stress in the workplace The nurses described that it was difficult for them to suffice when several people (patients, relatives, assistant nurses) were simultaneously in need of their help. The informants reported in the interviews that high workloads and staff shortages were the reasons why they still thought about work at home, which led to tiredness and irritation. Not having enough time to care for patients, due to increased time spent on administrative work, was frustrating. The nurses experienced a feeling of emotional powerlessness when there was not sufficient time, which decreased their chances to take care of the patients in a way they saw fit. The nurses' understanding that they could not influence their work situation caused them to have a feeling of hopelessness Harmful stress arises when leadership places high demands that are not balanced by employees' influence over their work. In situations of imbalance, such as staff shortages and heavy workloads, employees feel worn out and tired, which can lead to reduced self-confidence. Absence of response from supervisors can cause imbalance in an entire workplace. o Burnout and the Med-Surg Nurse Burnout results from the inability to adequately manage work-related stress. This happens when workloads are too heavy, a sense of empowerment is missing, or ideals are greatly mismatched with reality. With such large patient loads, it becomes a challenge to pro- vide the needed care to all patients, adding to the sense of frustration and reduced personal accomplishment. o Stressors, burnout and social support Lack of adequate staffing was the main stressor reported by qualified staff, while dealing with physically threatening, difficult or demanding patients was the most stressful aspect for unqualified staff. Qualified nurses reported significantly higher workload stress than unqualified staff. Approximately half of all nursing staff showed signs of high burnout in terms of emotional exhaustion. A variety of stressors were positively correlated with emotional exhaustion and depersonalization. Higher levels of support from co-workers were related to lower levels of emotional exhaustion. Higher stressor scores were associated with higher levels of depersonalization for staff reporting high levels of social support, but not for those reporting low levels of support (a reverse buffering effect). The main stressor cited by qualified staff was a lack of adequate staffing, which is consistent with the findings of a number of previous studies of mental health nurses (Carson et al. 1995, Cushway et al. 1996). o Turkish nurses; perspectives on a program to reduce burnout Most of the nurses described work overload, insufficient staff, being undervalued and misunderstood by the administration as the causes of burnout. o Work-related fatigue and recovery Taken together, our results failed to demonstrate that full- time working nurses with domestic and dependent responsibilities are more 'at risk' of low recovery from acute work fatigue between shifts, and consequently developing mal- adaptive fatigue symptomology, compared with unpartnered nurses without dependents. All our analyses confirmed that working multiple shifts, which include night work, was associated with higher acute work- related fatigue, poorer intershift recovery and higher maladaptive chronic fatigue. These observations are consistent with many other reports of the relationship between shift- work and work strain (Tasto et al. 1978, Baker 1980, Kandolin 1993, Harrington 1994, Cruz et al. 2000, Akerstedt et al. 2002, Folkard & Tucker 2003 o When does nursing Burnout begin? Relatively inexperienced, newly graduated, nurses also commonly experience significant anxieties about clinical competency and role ambiguity (Healy & McKay 2000, Chang & Hancock 2003 In addition, they begin working the unpredictable internal shift rotation system (including night duty) which is traditional within nursing, and of which younger nurses are expected to do far more. (Learthart 2000, Winwood et al. 2006b). Support o Stress and burnout in forensic mental health nursing: a literature revision Burnout, however, is an elusive concept; moreover, in 1974 Freudenberger suggested that certain commonalities and themes pervaded the literature. Burnout is a psychological experience that manifests itself in the individual, particularity those involved in difficult person-to-person relationships as part of their working practice. In accord with Kirby and Pollock (1995) and Cacciacarne et al (1986), Chalder and Nolan (2000) conclude that staff should have easy and confidential access to support systems within the workplace and that managers should foster an open and honest culture wherein individuals can feel free to speak up for themselves and others about issues that are causing stress. o Working Conditions, psychosocial resources and works stress According to Johnson (1991) social support at work and job support might function as an important coping resource, which potentially may modify the impact of social environmental stress Nurse managers who reported low instrumental support more than doubled their probability of high level of work stress The results indicated that the job demands on nurse managers and clinical directors might have become too high to be buffered within ordinary supporting limits related to the work situation. Both nurse managers and clinical directors who were exposed to high job demands had significantly increased odds for high level of work stress regardless of the available psychosocial resources taken together in daily life (inside and outside work) One finding in this study was the nurse managers' experience of high level of work stress in relation to low instrumental support, which was not found in the group of clinical directors. Here, the nurse managers more than doubled their probability for high level of work stress. A possible explanation to this finding might be that the nurse managers, who historically just entered higher structural levels of chief management, by tradition and/ or organizational culture do not require essential instrumental support from other professional groups within the organization. o Work-related stress, education and work ability among hospital nurses In the last few years, there has been growing interest in the psychosocial work environment of healthcare workers. This is because they are at high risk of stress, burnout, role conflict and job dissatisfaction. o Job stress, achievement motivation and occupational burnout among male nurse Nurses who work in very stressful environments with minimal control and organizational interaction from colleagues may actually have a negative effect on patient safety (Berland et al. 2008). In addition, nurses with frequent job stress could experience numerous psychological and physical problems (Wong et al. 2001) o Burnout among hospital nurses in China Nurses who claimed to receive enough support from friends had a significantly lower level of Depersonalization, while nurses with support from coworkers and managers experienced significantly lower levels of Emotional Exhaustion o Contrasting burnout, turnover intention,... Individuals who assert a high self-rating for control believe they have the capaci