Data collection and Analysis

Recruitment and Retention of Health Care Providers in Remote Rural Areas Data collection and Analysis Results from online survey January 2013 Hjördís Sigursteinsdóttir Eva Halapi

Recruitment and Retention of Health Care Providers in Remote Rural Areas Data collection and Analysis Results from online survey January 2013 Hjördís Sigursteinsdóttir Eva Halapi Verknúmer R11038KAN Jan 2013 Bls. 2

RHA-University of Akureyri Research Centre RHA-S-07-2012 L-ISSN 1670-8873 Jan 2013 Bls. 3

Table of Contents 1. INTRODUCTION... 5 2. METHODS... 6 3. BACKGROUND INFORMATION... 9 3.1 PERSONAL INFORMATION... 9 3.2 WORKPLACE AND TRAINING... 10 3.3 WORK EXPERIENCE AND EMPLOYMENT STATUS... 12 3.4 EXPERIENCE OF RURAL AREAS... 14 4. PROFESSIONAL ASPIRATIONS...21 4.1 CURRENT JOB... 21 4.2 WORKING CONDITIONS... 22 4.3 LOYALTY... 24 4.4 CAREER PATHWAY... 25 4.5 IDEAL JOB... 26 4.6 REASONS FOR LEAVING... 29 5. ISOLATION...31 6. FAMILY NEEDS AND EXPECTATIONS...34 6.1 THE COMMUNITY... 34 6.2 LEISURE ACTIVITIES... 34 6.3 CURRENT SITUATION... 35 7. URBAN VS RURAL...38 7.1 FACTORS IMPORTANT FOR CURRENT JOB... 38 7.2 WORK MOTIFS... 39 7.3 LOYALTY... 40 7.4 IDEAL JOB... 41 7.5 REASONS FOR LEAVING JOB... 42 7.6 ISOLATION... 42 7.7 NEEDS AND EXPECTATIONS... 43 8. COMMENTS FROM PARTICIPANTS...46 8.1 INTENDED CAREER PATHWAY... 46 8.2 IDEAL JOB... 47 8.3 GENERAL COMMENTS... 49 9. CONCLUSIONS...52 Jan 2013 Bls. 4

1. Introduction This report contains the results from a survey conducted among health care professional and health care undergraduate students in seven countries; Canada, Greenland, Iceland, Ireland, Norway, Scotland and Sweden. It is part of the project: Recruitment and Retention of Health Care Providers in Remote Rural Areas, which is funded by the European Regional Development Fund within the Northern Periphery Programme. The main purpose of the project is to find a solution to the burgeoning difficulties of recruiting and retaining a high quality, sustainable health care workforce for remote rural areas. The study will explore/evaluate issues relating to training and education, maintaining of skills, isolation among employees in addition to psychological effects associated with living in rural areas. The results, presented in this report, were developed as part of work package 2 entitled; Data collection and analysis. The aim of work package 2 is to gain information about the situation in each partner region regarding recruitment and retention at the present time. To provide baseline information for future comparisons. To produce accurate data on the motivating and demotivating factors affecting recruitment and retention of front line health care workers. To analyse this data and use it to direct the development of products and services aimed at supporting the development of a sustainable and high quality health care workforce for remote rural areas. Jan 2013 Bls. 5

2. Methods This research was conducted through an online survey among health care professional and health care undergraduates in seven countries; Canada, Greenland, Iceland, Ireland, Norway, Scotland and Sweden. The questionnaire was developed by University of Akureyri Research Centre (RHA) in collaboration with partners in the project. The selection of participants and the way to approach participants was somewhat different between countries and this will be described in brief below. Canada: In Canada the survey was sent out to all the NOSM clinical faculty members and all NOSM post-graduate trainees, a total 1266 participants. The response rate was 24.2% (306 responses). Greenland: In Greenland participants were selected from a database of healthcare professionals - doctors, nurses, midwives, laboratory technicians, dentists, occupational therapists and physiotherapists. All health professional staff with a long-term higher education was given the offer to participate The survey was sent out by e-mail to all health care professionals and health care undergraduate in Greenland with e-mails, a total of 594. The response rate was 38.2% (227 responses). Iceland: In Iceland the target groups were doctors, registered nurses, midwives and dentists in Iceland along with senior year health care students from University of Iceland and University of Akureyri. The survey was distributed by e-mails to students, dentists and midwives, a total of 842. A web-link was made for doctors and registered nurses and distributed by e-mail by their unions. According to the unions, a total of 3,463 members could access those links. A total participant in Iceland was 4,305. The response rate was 36.0% (1,551 responses). Ireland: In Ireland the sample consisted of employees of Northern Health & Social Care Trust, Southern health & Social Care Trust, South-Eastern Health & Social Care Trust, Western health & Social care Trust, HSE West (Republic of Ireland) and HSE South (Republic of Ireland), a total of 1,853. The participants could access the survey through a web-link. The response rate was 20.2% (375 responses). Norway: The sample for Norway consisted of primary health care professionals (medical doctors, registered nurses and midwives) in the region of Finnmark and Tromsö and senior year health care students. Also invited to participate were specialist doctors from six different clinics (Acute medicine, General psychiatric care, Surgery, oncology and women s health, General medicine, Operations and intensive care, Children and adolescents, Substance abuse and special psychiatric care), Jan 2013 Bls. 6

midwives and registered nurses working on the University hospital (UNN) in Tromsö. A web-link was provided by email to employees at Helse Finnmark, trade union members in Finnmark and Tromsö was contacted by emails to the respective professional category to, employees at UNN were contacted by direct email and the survey was also advertised on the UNN intra website and to health care students who had provided their email to the respective school. In total 3,635 could access the survey in Norway. The response rate was 30.8% (1,118 responses). Scotland 1: There were seven target groups, Western Isles NHS current staff, Grampian NHS current staff, NoSPG members, Western Isles NHS former staff, Western Isles Junior Doctors current, Western Isles Junior doctors, and Western Isles Student nurses, total 14,674. The participants could access the survey through a web-link. The response rate was 3.8% (560 responses). The low response rate for the Scottish sample was due to that for one group (NHS Grampian urban comparator) the survey links was accessible to 12,500 individuals but no more than 94 responses were received. There were no possibilities to assess how many actually did access the website containing the survey link. Excluding the Grampian group the response rate for the Scotland 1 samples was 21.4% (466). Scotland 2: In Highland the survey was sent out by e-mail to healthcare professionals and nursing undergraduates based in Highland. Some e-mails were sent to managers who disseminated amongst their team. An estimated 2000 people were targeted. The response rate was 20.2% which was poor due to technical issues with a strict Firewall on NHS computer systems. Sweden: In Sweden the survey was sent out by e-mail to all health care professionals and health care students in the region of Västerbotten, a total of 1,528. The response rate was 36.0% (550 responses). Jan 2013 Bls. 7

Table 1. Summary of sample type and size and response rates among partners Population/sample Total participants in population/sample: Responses Response rate Canada population 1,266 306 24.2% Greenland population 594 227 38.2% Iceland population 4,305 1551 36.0% Ireland sample 1,853 375 20.2% Norway population 3,635 1118 30.8% Scotland 1 sample 14,674* 560 3.8% Scotland 2 sample 2,000 403 48.2% Sweden population 1,528 550 36.0% Total: 29,855 5090 17.0% Without NHS Grampian urban comparator (see explanation below) 2,174 4,996 28,8% *The low response rate for the Scottish sample was due to that for one group (NHS Grampian urban comparator) the survey links was accessible to 12,500 individuals but no more than 94 responses were received. Excluding the Grampian group the response rate for the Scotland 1 samples was 21.4%. Data collection was conducted from 6 th of September to 11 th of October, except for Greenland, where data collection was conducted from 7 th of December to 5 th of January 2013. Three reminding letters were sent out after the first invitation letter. Statistical analyses were carried out using SPSS software package assessing frequencies in the total samples and differences between groups (gender, age, profession, urban or rural work place and individual partners). The results are presented in figures and tables along with a minimum level of interpretation of the results. Kendall s tau-c was used to measure the strength of the relationships between variables. It measures the correlation between variables and takes the values between minus one and plus one. A positive correlation indicates that the ranks of both the variables are increasing or decreasing. On the other hand, a negative correlation indicates that while the rank of one variable is increasing, the rank of the other variables is decreasing. We used Pearson R correlation to measure the association between two variables that are on an interval scale. The correlation coefficient is a number between +1 and -1. The closer the correlation is to either +1 or -1, the stronger the correlation. Jan 2013 Bls. 8

3. Background information This chapter describes the results pertaining participants background information. The chapter is divided into 4 subsection (3.1) Personal information (3.2) Workplace and Training (3.3) Work experience and employment status and (3.4) Experience of rural areas. 3.1 Personal information Figure 1 shows the gender distribution in the total sample. The majority of participants in the study were females (78%). For about 1 in 10 participants (n=458) information on gender was missing. Male Female Figure 1. Gender. Figure 2 shows the age distribution in the total sample. Close to half of the sample (48%) is 46 years or older whereas 27% of participants are younger than 35 years of age. For about 1 in 5 participants (n=977) information on age is missing. Average age of participants is 44.4 years, highest among participants in Canada, Iceland, Scotland 1 (46 years) and lowest in Ireland (41 years) and Norway (42 years). <35 years 36-45 years 46-55 years > 56 years Figure 2. Age. Figure 3 shows the marital status among participants for the total sample. The majority of participants were in a partnership, where 60% were married and 19% lived in consensual union. A smaller proportion of participants reported they were either single (14%), divorced/ separated (7%) or widowed (1%). For about 14% of participants (n=730) information on marital status was missing. Jan 2013 Bls. 9

Single Widowed Divorced/separated Married Consensual union Figure 3. Marital status. Figure 4 shows the number of people living in household with participants by age. Most participants share household with adults, but more than half of them (54%) live with children who are 20 years and younger. About 18% of the households have two children 20 years and younger while 15% have one. Most common age of the children was 6-12 years old. < 1 year 1-5 years 6-12 years 13-16 years 17-20 years > 20 yrs None One Two Three Four Five or more than five Figure 4. Number of people living in the household. 3.2 Workplace and training This section presents results pertaining to questions on workplace and training and encompasses questions 13-17 in the survey. The majority of participants were licensed/registered health care professional (87%) whereas health care students and postgraduate trainees represented 8% and 4% of the total sample respectively (Figure 5). For about 1 of 10 participants (n=503) information on professional or student status was missing. Jan 2013 Bls. 10

Health care student Licensed/registered health care professional Postgraduate trainee health care professional Figure 5. I am a health care student, postgraduate trainee health care professional or a licensed/registered health care professional. Medical student (43%) represented the largest proportion among health care students followed by nursing students (37%) and dental students (12%) (Figure 6). No. 180 160 140 120 100 80 60 40 20 0 Medical student Dental student Nursing student Midwifery student Other health care student Figure 6. Current student status. Figure 7 shows the distribution of health care professional categories for the total sample. The majority of health care professionals were registered nurses (46%), followed by medical doctors (28%) and others (18%). In contrast, a relatively small proportion of health care professionals were midwives (5%) or dentists (4%). Jan 2013 Bls. 11

No. 2500 2000 1500 1000 500 0 Dentist Medical Doctor Midwife Registered Nurse Other Figure 7. What is your profession? 3.3 Work experience and employment status Questions 24-27 and 29 assessed work experience and employment status. The majority of participants (60%) had 15 years or more of working experience. In contrast, the proportion of participants with less than 1 year of working experience was small (2%). The proportion of participants with 11-15 years, 6-10 years and 1-5 year of work experience was 13%, 12% and 13% respectively (Figure 8). < 1 years 1-5 years 6-10 years 11-15 years > 15 years Figure 8. What is your work experience in years as a health care professional? Figure 9 shows the proportion of health care professionals in the total sample working full (59%) or part time (41%). A greater proportion of males (75%) than females (54%) worked fulltime. There was also a difference when comparing professional categories where 72% of medical doctors and other health professionals worked fulltime compared to 46% of registered nurses /midwives. (See further details annex Tables 96-97). Jan 2013 Bls. 12

Part time Full time Figure 9. Do you work part time or full time? Figure 10 shows current employment status (permanent, temporary or locum) for health care professionals in the total sample. The majority (89%) of licensed/registered health care professionals had a permanent position. Close to 7% reported having a temporary position whereas around 5% health care professionals were in locum work. Much lower proportion of participants 35 years and younger had permanent employment or 75% compared to other age groups in where 91% or more said to have and permanent position. The proportion of medical doctors with permanent position was somewhat lower (82%) compared to registered nurses /midwives (91%) or other health professionals (91%). (See further details annex Tables 98-99) Permanent Temporary < 3 months Temporary > 3 months Locum < 3 months Locum > 3 months Figure 10. What is your main current employment status? The proportion of self-employed health care professional was 15 % in the total sample (Figure 11). With higher age a greater proportion of participants are selfemployed. A greater proportion of medical doctors were self-employed (35%) compared to registered nurses/ midwifes (5%) and other health professionals (15%). A greater proportion of participants currently working/studying in rural areas were self-employed (20%) compared to those working/studying in urban areas (14%). (See further details annex Tables 100-101) Jan 2013 Bls. 13

Yes No Figure 11. Are you self-employed? Figure 12 shows the distribution of different types of remuneration (salary, capitation, activity/fee for service or a combination) that health care professional in the total sample were receiving. The majority of participants received salary (85%). A combination of different types of remuneration was said to be received by 10% of health care professionals whereas activity/fee for service based payment was reported by 4% and capitation by 1% of health care professionals. A higher proportion of males compared to females said to receive other types of remuneration than salary. This was also true for participants 56 years and older, medical doctors and participants currently working/studying in rural areas. (See further details annex Tables 104-105). Salary Capitation Activity/fee for service Combination Figure 12. What type of remuneration do you receive? 3.4 Experience of rural areas Question 2-10 assessed participants experience of rural areas. Among the participants, communities with populations smaller than 5,000 was regarded as rural by 80% while communities with populations of 10,000 and greater was regarded as urban by 76% of participants (Figure 13). Jan 2013 Bls. 14

Population of <1,999 Population of 2,000-4,999 Population of 5,000-9,999 Population of 10,000-24,999 Population of 25,000-100,000 Population of >100,000 Urban Rural Figure 13. What community size do you consider to be urban or rural? About half of the participants considered themselves to have a rural background (Figure 14). More females than males (52% vs. 42%) regarded themselves as having a rural background. Less than half of the medical doctors (44%) said to have a rural background while 50% of registered nurses/ midwives and 57% of other health care professionals regarded themselves as having a rural background. Among participants currently working/ studying in a rural area, 64% regarded themselves as to have a rural background in contrast participants currently working/studying in urban areas where 44% regarded themselves as having a rural background. (See further details annex Tables 16-17). Yes No Figure 14. Do you consider yourself to have a rural background? The majority of participants (62%) said to currently be living in urban area whereas 38% said to currently be living in a rural area (Figure 15). With higher age a greater proportion of participants were currently working/studying in rural areas. Among participants aged 35 and less the proportion with current residency in a rural area was 30%, while among 36-45 and 46-55 years old 40% and 42% respectively lived in a rural area. Among participants 56 years and older 36% said their current residence Jan 2013 Bls. 15

was in rural areas. A higher proportion among medical doctors were currently living in rural areas (41%) compared to registered nurses or midwives (31%) or other health care professionals (47%). There was a strong correlation between living and working in urban or rural area (r=.69, n=4980, p<.0001). (See further details annex Tables 18-19). Urban Rural Figure 15. Please tick urban or rural according to your current residence. Figure 16 shows how participants living in rural areas rated accessibility for their current place of residence (accessible, remote or very remote). Nearly 6 of 10 participants living in rural areas rated accessibility as remote (21%) or very remote (39%) while 40% rated their current residence as accessible. A greater proportion of males compared to females rated their accessibility as very remote (44% vs 37%), along with participants in the youngest age group. Here 46% rated their accessibility as very remote while the proportion ranged from 38 to 40 % in other age groups. A greater proportion of medical doctors than registered nurses/midwives or other health care professionals rated the accessibility for their current place of residence as very remote (59% vs 45 and 41% respectively). (See further details annex Tables 20-21). Accessible (< 30 min from urban by car) Remote (30-60 min from urban by car) Very remote (> 60 min from urban by car or not accesible by car) Figure 16. How would you rate your current residence in terms of accessibility? The majority of participants said to work/study in an urban area (71%) whereas 29% said to work/study in rural areas (Figure 17). The proportion of males who work/study in rural areas was greater compared to females (34% vs 29%). (See further details annex Tables 22-23) Jan 2013 Bls. 16

Urban Rural Figure 17. Please tick urban or rural area according to your place of work/place of study. About 1 of 5 participants (19%) currently working /studying in rural areas commuted at least once a week whereas 22% said to commute few time a month to urban areas in relation to work or study (Figure 18). Medical doctors said to commute less often in relation to their work/study than registered nurses/midwives or other healthcare professionals. (See further details annex Tables 24-25) Every day 2-3 times a week Once a week A few times per month Not applicable Figure 18. Do you need to commute to urban areas in relation to your work/study? Figure 19 shows how participants working/studying in rural areas rated accessibility of current place of work or study (accessible, remote or very remote). Among participants with current place of work/study in rural areas, 48% rated accessibility as very remote, 21% rated accessibility as remote while 31% rated their current work/study location as accessible. A greater proportion of males than females rated their current place of work as very remote (53% vs 46%). A greater proportion of medical doctors rated their current place of work as very remote compared to registered nurses/midwives or other health care professionals. (See further details annex Tables 26-27). Accessible (< 30 min from urban by car) Remote (30-60 min from urban by car) Very remote (> 60 min from urban by car or not accesible by car) Figure 19. How would you rate your current place of work/study in terms of accessibility? Jan 2013 Bls. 17

Figure 20 shows the proportion of health professionals experience of working in rural areas. Sixty percent of respondents (n=2115) said to have ever worked in rural areas. Close to half of those who said to have worked in rural areas (46%) had done so for more than 12 months while 40% said to have worked for a period 6 months or less. A greater proportion of females than males had never worked in rural area (45% vs. 26%). With increasing age a greater proportion of participants said to have ever worked in rural areas. A greater proportion of medical doctors (79%) than registered nurses/midwives (54%) or other health care professionals (58%) had ever worked in rural area. Among those who said to have ever worked in rural areas, a greater proportion of other health care professionals had worked in rural area for more than 12 months compared to medical doctors or registered nurses/midwives. (See further details annex Tables 28-29) No Yes, less than 3 months Yes, between 3-6 months Yes, 6-12 months Yes, more than 12 months Figure 20. Have you ever worked in rural area? The majority health professionals (72%) said to have lived in an urban area during their school education while 28% said to have lived in a rural area (Figure 21). A greater proportion of females compared to males said to have lived in a rural area during the majority of their school education (31% vs. 22%). A smaller proportion of participants in the oldest age group (22%) compared to participants in other age groups (28-30%) had lived in rural areas during the majority of school education. A greater proportion of other health care professionals compared to medical doctors or registered nurses/midwives had lived in rural areas during majority of their school education. There was a significant correlation between living in rural areas during majority of school education and currently working/studying in urban or rural area (r=.20, n=4849, p<.0001). (See further details annex Tables 30-31) Jan 2013 Bls. 18

Urban Rural Figure 21. Please tick urban or rural area according to your place of residence during majority of school education. Figure 22 shows how health professionals whose place of residence during school education was in rural areas rated accessibility (accessible, remote or very remote). About half of the respondents rated accessibility as remote or very remote (28% and 25% respectively) while 48% rated their current residence as accessible. A greater proportion of registered nurses or midwives compared to medical doctors and other health care professionals rated accessibility as very remote (30% vs 19-24%). There was a significant difference in how participants rated the accessibility for their residency during education based on current location of work/study. More than half of participants currently working/studying in urban area (55%) rated their residence during majority of school education as accessible while 38% of participants currently working/studying in rural area rated it as accessible. A smaller proportion of those currently working/studying in an urban area (19%) compared to those in rural areas (34%) rated accessibility to their residence during majority of school education as very remote. (See further details annex Tables 32-33). 644 374 337 Accessible (< 30 min from urban by car) Remote (30-60 min from urban by car) Very remote (> 60 min from urban by car or not accesible by car) Figure 22. How would you rate your place of residence during majority of school education in terms of accessibility? Figure 23 shows the proportion of licensed/registered health care professionals (34%) in the total sample who undertook part of their health care training in a rural area. A significantly greater proportion of males (42%) than females (32%) said to have trained in rural areas. Having done health care training in rural areas was more common in the younger age groups. Significantly more medical doctors (50%) Jan 2013 Bls. 19

compared registered nurses/midwives (27%) or other health professionals (26%) had undertaken their health care training in a rural area (See further details annex Tables 34-35). Yes No Figure 23. Was any of your health care training undertaken in rural area? Jan 2013 Bls. 20

4. Professional aspirations This chapter describes the results pertaining to questions on participants professional aspirations. The chapter is divided into 6 subsections (4.1) Current job (4.2) Working conditions (4.3) Loyalty (4.4) Career pathway (4.5) Ideal job and (4.6) Reasons for leaving. 4.1 Current job This section assesses factors relevant for participants when commencing current or future work and encompasses question 32 in the survey. The factors deemed as most relevant by health professionals when commencing a job at current/future workplace were that the job suited the education (91% agreed or strongly agreed), job security (76% agreed or strongly agreed) and working conditions (74% agreed or strongly agreed). The factors deemed as less relevant included participant or spouse being raised there or previous clinical placement (21%, 18% and 23% agreed or strongly agreed respectively). The job suited my education Job security Working conditions Flexible working hours Limited opportunities elswhere Education possibilities Career possibilities Reputation of employing organisation I was raised there Social and recreational activities Financial remuneration Leisure activities Availability for supervision /mentoring My spouse was raised there I had my clinical placement there Strongly disagree Disagree Neither nor Agree Strongly agree Figure 24. What is your level of agreement to the following statements? Jan 2013 Bls. 21

Significant differences between males and females were observed for the level of agreement/disagreement on factors important for commencing job at current/future workplace. The significant difference was valid for all the assessed factors except the statements I had my clinical placement here and My spouse was raised here. Males agreed to a greater extent on factors as Financial remuneration, Leisure activity and Social and recreational activities whereas females tended to agree to a greater extent for all other statements. Significant differences were also observed between professional categories. With respect to e.g. Job security or Limited opportunities elsewhere nurses/midwives and other health professionals tended to agree to a greater extent than did medical doctors that these were important when starting a job at current/future workplace. In contrast, medical doctor agreed to a greater extent that I had my clinical placement here or Leisure activities were important factors. (See further details annex Tables 142-172). 4.2 Working conditions This section presents results pertaining to working conditions and encompasses question 33 in the survey. The factors deemed as most relevant by health professionals were to be able to Apply knowledge and expertise (96% agreed or strongly agreed) Respect of colleagues (92% agreed or strongly agreed) Wages (87% agreed or strongly agreed) and Keeping busy at work (82% agreed or strongly agreed). The factors deemed as less relevant included Occupation of spouse having an impact on choice of residency and being Able to work shifts/overtimes for extra salary (47% and 36% agreed or strongly agreed respectively). Jan 2013 Bls. 22

I want to get enough opportunities to apply my knowlegde and experience I want other colleagues to respect my job Wages are important I want to be busy at work I prefer to work in interdisciplinary teams I prefer to work close to my family (parents and/or siglings) I prefer to work daytime only I want to have clear and concise job description The occupation of my spouse will affect our choice of residency I would prefer to be able to work shifts / overfime for extra salary Strongly disagree Disagree Neither nor Agree Strongly agree Figure 25. What is your level of agreement to the following statements? Significant differences for how males and females rated their agreement for a number of factors were observed. In general, a greater proportion of females than males agreed strongly that the respective issue was an important factor in relation to work motifs. A relatively greater proportion of the younger age groups compared to the older age groups strongly agreed to that factors like Job description, Possibility to earn extra for shifts or overtime, Nearness to family and that Occupation of spouse for determining residency were important factors in relation to work motifs. Significant differences were also observed between professional categories. More nurses/midwives agreed strongly that Wages, Job description, Ability to earn extra on shift or overtime work were relevant factors in relation to work motifs. Being Able to work daytime only was more agreed to among other health professionals. (See further details annex Tables 173-193). Jan 2013 Bls. 23

4.3 Loyalty This section describes the results pertaining participants loyalty to organization and encompasses questions 18 and 28 in the survey. More than 4 of 10 health professionals agreed or strongly agreed that they will continue work with the current organization until retirement whereas 29% of health professional strongly disagreed or disagreed. The majority of health professionals (72%) strongly agreed or agreed that that they plan to work for the current organization for the next two years whereas 15% strongly disagreed or disagreed (Figure 26). I expect that I will work at this organisation until retirement I plan to work at this organisation for the next 2 years at least Strongly disagree Disagree Neither nor Agree Strongly agree Figure 26. Loyalty to the organization. There was a significant difference for how males and females rated their agreement on the statement whether to remain with the organisation until retirement in where a higher proportion of males than females strongly agreed or agreed. There was also a significant difference between age categories concerning loyalty to the organization. A higher proportion of participants in the youngest age group compared to other age groups strongly disagreed or disagreed on planning to work for the organisation for the next 2 years. With higher age a greater proportion of participants agreed or strongly agreed that they would remain with the organisation until retirement. Significant differences were also observed between professional categories. A relative greater proportion of other health care professional compared to nurses/midwives and medical doctor agreed or strongly agreed that they planned to work the next 2 years within the organisation. A relative lower proportion of nurses/midwives expect to remain at the same job until retirement compared to doctors and other health care professionals. (See further details annex Tables 44-46). More than 2 in 10 licensed/registered health professionals said they were very likely (11%) or extremely likely (12%) to look for another job outside the current workplace whereas 30% of participants said they were not at all likely to seek other Jan 2013 Bls. 24

employment (Figure 27). With increasing age a lower proportion of participants said they were very likely or extremely likely to look for another job outside the current workplace. (See further details annex Tables 102-103). Extremely likely Very likely Moderately likely Slightly likely Not at all likely Figure 27. How likely are you to look for another job outside the current workplace? 4.4 Career pathway This section describes the results pertaining participants views on intended career pathway and encompasses question 19 in the survey. Of the licensed/registered health professionals in the total samples, 53% intended to remain in their current role, 19% intended to develop into a specialist, and 12% intended to relocate to another organization to gain further experience. A marked effect was noted for choice of career pathway with respect to age. Here the older age group planned to remain in their current role, whereas a greater proportion of participant in younger groups saw it as likely or very likely to either develop in to a specialist or relocate to other organization. A greater proportion of medical doctors intended to remain in their current role (62%) compared to nurses/midwives (48%) and other health care professionals (54%). In contrast, a lower proportion of medical doctors (8%) compared to nurses or other health professionals (14% and 13% respectively) intended to relocate to another organisation to gain further experience. (See further details annex Tables 49-50). Jan 2013 Bls. 25

No. 2500 2000 1500 1000 500 0 Remain in current role Develop into a specialist 11,8% Relocate to another organisation to gain further experience Other Figure 28. Please indicate your intended career pathway. 4.5 Ideal job This section presents responses on questions pertaining to participants image on their ideal job (questions 30 and 31). Most participants ideal health care job was working in a hospital in an urban area, followed by primary care setting in rural area. Fewer participants ideal health care job would involve research/teaching at a university. In hospital in an urban area 1815 In primary health care in a rural area 1193 In primary health care in an urban area Working abroad In hospital in a rural area Research/teaching at a University Other 1020 922 883 776 792 0 200 400 600 800 1000 1200 1400 1600 1800 2000 No. Figure 29. What is your ideal health care job? A greater proportion of participants younger than 35 years of age (54%) than those older than 56 years (30%) of age said ideal job is in hospital in an urban area. More Jan 2013 Bls. 26

registered nurses/midwives and medical doctors (43% and 35% respectively) than other health professionals (21%) said ideal job is in hospital in an urban area. Also A greater proportion among participants currently working/studying in an urban area (45%) compared to those currently working/studying in a rural area (17%) said that their ideal job was in hospital in an urban area. A smaller proportion of nurses compared to medical doctors or other health professionals said ideal job to be in primary care in a rural area (17%, 31% and 31% respectively). A greater proportion of participants currently working/studying in a rural area (43%) than those working/studying in an urban area (16%) said ideal job to be in primary health care in a rural area A greater proportion of women (22%) than men (14%) said ideal job to be in primary healthcare in an urban area. A greater proportion among other health professionals (28%) than nurses and medical doctors (17% and 18% respectively) said ideal job to be in primary healthcare in an urban area. A greater proportion of participants currently working/studying in an urban area (25%) than those working/studying in an rural area (11%) said their ideal job to be in primary care in a urban area. (See further details annex Tables 106-120). The majority of health professionals strongly agreed to that Job satisfaction Work life balance, and Good team relationship, were important factors in relation to their ideal job (Figure 30). Jan 2013 Bls. 27

Job satisfaction Work life balance Good team relationship Personal development Employment security Good pay and material benefits Creatvie and innovative work opportunities Accredited funded training and development opportunities Ease of locum cover Research and development access Strongly disagree Disagree Neither nor Agree Strongly agree Figure 30. To what extent do you agree that the following factors would be important in relation to your ideal job? There were significant differences between males and females for all factors assessed. In general, a greater proportion of females than males strongly agreed that the respective factor was an important factor in relation to their ideal job. A relatively smaller proportion of those 56 years of age and older compared to the younger age groups strongly agreed that factors like Personal development, Jobs satisfaction, Employment security, Accredited funded training and development opportunities and Work life balance were important in relation to their ideal job. Significant differences were also observed between professional categories. A relative greater proportion of nurses/midwives compared to medical doctors or other health professionals agreed strongly that factors like Personal development, Good pay and material benefits, Employment security, Creative and innovative work opportunities and Accredited funded training and development opportunities were important factors in relation to their ideal job. (See further details annex Tables 121-141). Jan 2013 Bls. 28

4.6 Reasons for leaving Questions 22 and 23 assessed how many- and the reason for- participants leaving a post in a rural area. A minor proportion of health care professionals (4% n=182) had recently left a position in a remote rural area (Figure 31). Yes No Figure 31. Are you a health care professional who has recently (within 12 months) left post in a remote rural area? Among the health care professionals who recently had left a position in a remote rural area the main factors for leaving were Limited professional support (42% agreed or strongly agreed) Limited career possibilities (41% agreed or strongly agreed) and Family reasons (40% agreed or strongly agreed). The factors deemed as less relevant included, Job security, Reputation of organisation and Fitness of education to job (23%, 19% and 14% agreed or strongly agreed respectively). In the group of health professionals that had recently left their position in a rural area, significant differences were observed between males and females regarding the reasons for leaving. These included Fitness of education for job, Job security, Working conditions, Career possibilities, Reputation of organisation, and Financial remuneration. Men generally expressed greater level of agreement compared to women for these factors as decisive for leaving a post in a rural area. In contrast, Family reasons was more agreed or strongly agreed to as a factor for leaving a rural posting among women compared to men. (See further details annex Tables 71-93) Jan 2013 Bls. 29

Limited proffessional support Limited career possibilities Family reasons Lack of financial remuneration Working conditions were poor Inflexible working hours Lack of social and recreational activities Lack of leisure activities Lack of job security Bad reputation of employing organisation The job did not suit my education Strongly disagree Disagree Neither nor Strongly agree Figure 32. Consider the reasons in following statements. Jan 2013 Bls. 30

5. Isolation This section presents data on responses to questions on isolation and encompasses questions 20, 35 and 36 in the survey. The majority of participants disagreed or strongly disagreed on being isolated either professionally, geographically, culturally, socially or with respect to religious beliefs. However, about 1 of 4 participants agreed or strongly agreed to have experienced professional or geographical isolation. More males than females agreed or strongly agreed to experiencing geographical isolation (35% vs 24%). A similar trend was seen for cultural, social and religious isolation in where more males than female said to agree or strongly agree. Similarly, somewhat more men compared to women agreed or agreed strongly to have experienced professional isolation. (See further details annex Tables 51-61). I experience geographical isolation I experience professional isolation I experience cultural isolation I experience social isolation I experiance religious isolation Strongly disagree Disagree Neither nor Strongly agree Figure 33. Experience of professional, geographical, cultural, social and religious isolation. About half the participants said to have almost everyone or most of their friends live in the same area whereas 19% of participants said to have almost nobody or no friends in the same area (Figure 34). More females (53%) compared to males (42%) said to have almost everyone or most of their friends live in the same area. More males (25%) compared to females (17%) said to have almost nobody or no friends had in the same area. More nurses/midwives said to have almost everyone or most of their friends live in the same area compared to medical doctors and other health professionals (57%, 41% and 45% respectively). In contrast, more medical doctors and other health Jan 2013 Bls. 31

professionals compared to nurses/midwives said to have almost nobody or no friends in the same area (26%, 21% and 15% respectively). About twice as many participants currently working/studying in urban areas compared to those working in rural areas said to have almost everyone or most of their friends live in the same area (57% vs. 32%). More participants currently working/studying in rural areas compared to those working in urban areas said to have almost nobody or no friends had in the same area (32% vs 14%). (See further details annex Table 199-200). Almost everyone Most A few Almost nobody I have no friends in the sama area Figure 34. How many of your close friends live in the same area (same place, same municipality or close by)? About 4 of 10 participants said to have almost everyone or most of their close relatives living in the same area. A similar proportion, or 40% of participants said to have almost nobody or no close relative in the same area (Figure 35). More females (41%) compared to males (27%) said to have almost everyone or most of their close relatives living in the same area. More males (54%) compared to females (36%) said to have almost nobody or no close relatives in the same area. More nurses/midwives said to have almost everyone or most of their close relatives living in the same area compared to medical doctors and other health professionals (44%, 30% and 34% respectively), whereas more medical doctors compared to other health professionals and nurses/midwives to said to have almost nobody or no friends had in the same area (53%, 42% and 32% respectively). About twice as many participants currently working/studying in urban areas compared to those working/studying in rural areas said to have almost everyone or most of their friends living in the same area (45% vs. 22%). More participants currently working/studying in rural areas compared to those working in urban areas said to have almost nobody or no friends had in the same area (33% vs 57%). (See further details annex Tables 201-202) Jan 2013 Bls. 32

Almost everyone Most A few Almost nobody I have no relatives in the sama area Figure 35. How many of your close relatives live in the same area (same place, same municipality or close by)? Jan 2013 Bls. 33

6. Family needs and expectations This chapter presents data on responses to questions pertaining to views on communal inclusion, leisure activities and factors important in the participants current situation. 6.1 The community This section presents data in response to questions pertaining to being/taking part of the community and encompasses question 34 in the survey. The majority of participants in the total sample (74%) agreed or strongly agreed that they were part of the community and likewise the majority (77%) also agreed or strongly agreed to be ready to work jointly with other inhabitants in the community to make it better (Figure 36). I feel like part of the community I am ready to work with the inhabitants to make the community better Strongly disagree Disagree Neither nor Agree Strongly agree Figure 36. What is your level of agreement related to the following statements about the community? A higher proportion of respondents in the oldest age group agreed to be part of the community compared to other age groups. (See further details annex tables 194-198) 6.2 Leisure activities The section presents data from questions pertaining to supply, diversity and quality of suitable leisure activities and encompasses question 21 in the survey. The majority of participants were rather or very satisfied with supply, diversity and quality of suitable leisure activities(72%, 68% and 69% respectively) (Figure 37). Jan 2013 Bls. 34

Supply of suitable leisure activities Diversity of suitable leisure activities Quality of suitable leisure activities Very dissatisfied Rather dissatisfied Neither nor Rather satisfied Very satistied Figure 37. What is your satisfaction concerning your possibilities to participate in leisure activities? Significant differences were observed between males and females. Here women in general were more often than men very satisfied with all three aspects of leisure activities. Significant differences were observed between age groups for two of the three factors regarding leisure activities. A higher proportion of participants in the oldest age group were very satisfied with supply and diversity of leisure activities compare to other age groups. A significant difference was observed between the professional categories with respect to the supply of suitable leisure activities. A higher proportion of other health care professionals compared to doctors or nurses/midwives were not as satisfied with supply of suitable leisure activities. Significant differences were observed between participants working in rural or urban areas respectively, were in general respondents currently working/studying in rural areas were less satisfied with supply, diversity and quality of suitable leisure activities. (See further details annex Tables 62-68). 6.3 Current situation This section presents data from questions pertaining to factors viewed as important in participant s current situation and encompasses questions 37 and 38 in the survey. More than 7 of 10 health care professionals agreed or agreed strongly that Friends and family, Leisure activities an Affordable housing were important factors to their current situation (77%, 77% and 74% agreed or agreed strongly respectively)(figure 38). Jan 2013 Bls. 35

Friends and family Leisure activities Affordable housing Schooling Travel cost (home to work/study) Partner employment Shopping Access to entertainment Public transport Child care availability Strongly disagree Disagree Neither nor Agree Strongly agree Figure 38. Do you agree that the following factors are important to you in your current situation? There were significant differences between males and females for all factors assessed except Access to Entertainment and Leisure activities. In general, a higher proportion of females than males agreed or strongly agreed that the respective factor was an important to participant s current situation. There were also significant differences between age groups for all factors assessed except two (Travel cost and Public transport). In general, a higher proportion of participants 45 years old and younger compared to those older than 45 years of age agreed or strongly agreed that the respective factor was an important to participant s current situation. Furthermore, there was a significant difference between professional categories for all factors assessed except Schooling and Leisure activities. In general, a lower proportion of doctors than nurses/midwives and other health professionals agreed or strongly agreed that the respective factor was important to participant s current situation. (See further details annex Tables 203-222). Jan 2013 Bls. 36

Internet acess Leisure activities Shopping Access to entertainment Friends and family Schooling Affordable housing Public transport Partner employment Child care availability Yes No No applicable Figure 39. In your current situation, do you have the following? In general, the majority of health professionals had access to items such Internet, Shopping, Leisure actives and Schooling or Child care (when applicable). However, 21% reported not having Friends and family in the area, 18% did not have Public transport and 17% did not have Affordable housing in their current situation (Figure 39). Significant differences between males and females were observed for availability of Access to entertainment, Partner employment, Friends and family in the area and Public transport where more females than males reported having access to these aspects. Significant differences with respect to age groups were also observed for Access to entertainment, Schooling, Child care availability and Public transport. More nurses/midwives than doctors and other health professionals reported having access to Friends and family in the area and Public transport (80% vs 64-75% and 73% vs 63-68% respectively). (See further details annex Tables 224-243). Jan 2013 Bls. 37

7. Urban vs rural This section presents summarised data from comparisons between participants based on their current place of work (urban or rural setting), both on a global level as well as for individual partners. Significance and direction of correlation are indicated in the tables below, detailed data can be found in the annex tables. A negative correlation indicates that as one variable increases, the other decreases, and viceversa. A positive correlation indicate that as the value of one variable increases, the value of the other variable increases; as one decreases the other decreases. 7.1 Factors important for current job Comparison of factors important for the participants current job stratified by urban or rural work location revealed statically significant differences for all factors except Working conditions, I was raised there and Social and recreational activities in the total sample. A positive correlation was observed for My spouse was raised there, Financial remuneration and Leisure activities whereas a negative correlation was observed for other factors. In this respect, factors like Job security, Education possibilities and Career possibilities was to a greater extent agreed to constitute factors important when commencing job at current/future workplace among participants currently working/studying in an urban areas compared to those working/studying in a rural area. (See further details annex Tables 142-172). Jan 2013 Bls. 38

Total Canada Greenland Iceland Ireland Norway Scotland 1 Scotland 2 Sweden Table 2. Current job Urban vs. rural The job suited my education Job security Working conditions Limited opportunities elsewhere Education possibilities Career possibilities Availability for supervision/mentoring Flexible working hours Reputation of employing organisation I had my clinical placement there I was raised there My spouse was raised there Financial remuneration Leisure activities Social and recreational activities Statistical significance between urban and rural with negative correlation Statistical significance between urban and rural with positive correlation 7.2 Work motifs Statistically significant differences, pending on location of workplace, with respect to factors important for working conditions included Wages, Job description, Nearness to family, Keeping busy at work and Respect from colleagues. For all significant factors a negative correlation was observed. In this respect, participants currently working/studying in urban areas to a greater extent agreed the various factors being important determinants compared to those working/studying in a rural area. (See further details annex Tables 173-193). Jan 2013 Bls. 39

Total Canada Greenland Iceland Ireland Norway Scotland 1 Scotland 2 Sweden Table 3. Working conditions Urban vs. rural I prefer to work in interdisciplinary teams Wages are important I want to have clear and concise job description I prefer to work daytime only I would prefer to be able to work shifts/overtime for extra salary I prefer to work close to my family (parents and/or siblings) I want other colleagues to respect my job I want to be busy at work The occupation of my spouse will affect our choice of residency I want to get enough opportunities to apply my knowledge and experience Statistical significance between urban and rural with negative correlation Statistical significance between urban and rural with positive correlation 7.3 Loyalty None of the views related loyalty to organisation was found to be significantly different among participants when stratified by work location in the total sample. Among individual partner countries, respondents in Greenland currently working in a rural setting expressed greater level of disagreement regarding remaining in the current role for another 2 years or remain within the current organization until retirement compared to those currently working in an urban setting. Respondents currently working in rural settings in Greenland, Iceland and Norway tended more likely to seek a job outside the current organization compared to those with a current workplace in an urban setting. In contrast, majority of participants in Canada irrespective of whether their current workplace was in an urban or rural setting said to not at all likely to seek a job outside the current organization. However, a greater proportion of those currently working in a rural setting compared to those in an urban setting said to be not at all likely to seek a job outside the current organization. (See further details annex Tables 44-46 and 102-103). Jan 2013 Bls. 40

Total Canada Greenland Iceland Ireland Norway Scotland 1 Scotland 2 Sweden Total Canada Greenland Iceland Ireland Norway Scotland 1 Scotland 2 Sweden Table 4. Loyalty Urban vs. rural I plan to work at this organisation for the next 2 years I expect that I will work at this organisation until retirement How likely are you to look for another job outside of the current workplace? Statistical significance between urban and rural with negative correlation Statistical significance between urban and rural with positive correlation 7.4 Ideal job When assessing factors important in relation to participants ideal job statistical significance between participants stratified by their work location for all but Personal development, Job satisfaction, Ease of locum cover and Work life balance was observed in the total sample. A positive correlation was observed for Good team relationships whereas other factors were negatively correlated in the total sample. A greater proportion of participants with current place of work/study in urban areas strongly agreed to that factors like Good pay and material benefits, Employment security, Creative and innovative work opportunities, Research and development access, and Accredited funded training and development opportunities were important in relation to their ideal job. Table 5. Ideal job Urban vs. rural Personal development Good pay and material benefits Job satisfaction Employment security Creative and innovative work opportunities Research and development access Accredited funded training and development opportunities Ease of locum cover Good team relationship Work life balance Statistical significance between urban and rural with negative correlation Statistical significance between urban and rural with positive correlation Jan 2013 Bls. 41

Total Canada Greenland Iceland Ireland Norway Scotland 1 Scotland 2 Sweden In Canada, Greenland, Iceland and Norway a significantly greater level of agreement was observed among those with a current work place in a an urban setting compared to those whose current workplace was in a rural area that Access to research and development was an important factor in relation to their ideal job. (See further details annex Tables 121-141). 7.5 Reasons for leaving job When comparing views among participants that recently had left a position in a rural setting stratified on current work location one responses option Bad reputation of employing organisation showed a statically significant positive correlation based on current workplace in the total sample. In this respect respondents currently working in a rural area were more likely to agree strongly and less likely to disagree compared to those currently working in an urban area that bad reputation of the employing organisation for a reason for recently leaving a position in a rural area. (See further details annex Tables 71-93). Table 6. Reasons for leaving post Urban vs. rural The job did not suit my education Lack of job security Working conditions were poor Limited career possibilities Limited professional support Inflexible working hours Bad reputation of employing organisation Family reasons Lack of financial remuneration Lack of leisure activities Lack of social and recreational activities 7.6 Isolation A positive correlation was observed for all assessed aspect of isolation in the total sample as well as in most the individual data sets. Most participants disagreed to feeling professional, social, cultural, geographical or religious isolation. There were marked differences between participants experiences of isolation depending on location of current workplace. A significantly greater proportion of participants Jan 2013 Bls. 42

Total Canada Greenland Iceland Ireland Norway Scotland 1 Scotland 2 Sweden currently working in rural areas (40%) compared to participants currently working in urban areas (18%) agreed or strongly agreed to have experience professional isolation. Similarly, a greater proportion of participants currently working in rural areas agreed or strongly agreed to have experienced geographical isolation (46% vs. 16%), cultural isolation (27% vs 7%) social isolation (25% vs 8%) and religious isolation (7% vs 3%) respectively. Respondents currently working/studying in an urban area generally disagreed to a greater extent than those currently working/studying in a rural area. (See further details annex Tables 51-61). Table 7. Isolation Urban vs. rural I experience professional isolation I experience social isolation I experience cultural isolation I experience geographical isolation I experience religious isolation NA Statistical significance between urban and rural with negative correlation Statistical significance between urban and rural with positive correlation NA Not applicable 7.7 Needs and expectations A positive correlation was observed for level of agreement related to the community in the total sample and also among most of the individual data sets in that the majority of participants agreed that they felt like part of the community and expressed willingness to work towards improving it. Respondents currently working in rural areas were in general agreeing to a greater extent compared to respondents currently working in urban areas. (See further details annex tables 194-198). A significant negative correlation was observed for supply, diversity and quality of leisure activities in the total samples as well as for most of the individual data sets. In general respondents currently living in a rural area were less satisfied with all aspects of leisure activities compared to respondents currently working in an urban area. (See further details annex Tables 62-68). Significant negative correlations was observed for all factors assessed regarding important factors to participants current situation in the total sample as well as for several of the individual data sets. Respondents currently working in urban areas Jan 2013 Bls. 43

Total Canada Greenland Iceland Ireland Norway Scotland 1 Scotland 2 Sweden were in general agreeing to a greater extent compared to respondents currently working in rural areas. (See further details annex Tables 203-222). Table 8. Family needs and expectations Urban vs. rural I feel like part of the community I am ready to work with the inhabitants to make the community better Supply of suitable leisure activities Diversity of suitable leisure activities Quality of suitable leisure activities Important factors Affordable housing Important factors Access to entertainment Important factors Shopping Important factors Schooling Important factors Leisure activities Important factors Travel cost Important factors Partner employment Important factors Child care availability Important factors Friends and family Important factors Public transport Availability Affordable housing Availability Access to entertainment Availability Shopping Availability Schooling Availability Leisure activities Availability Internet access Availability Partner employment Availability Child care availability Availability Friends and family Availability Public transport Statistical significance between urban and rural with negative correlation Statistical significance between urban and rural with positive correlation A significant positive correlation was observed many of the factors assessed regarding important factors for participants current situation in the total sample as well as for several of the individual data sets. Availability of entertainment, shopping, schooling, leisure activities, employment for partner, child care, friends and family in Jan 2013 Bls. 44

the area and public transport differed significantly depending on urban or rural area for current place of work/study. For example 38% of those currently working/studying in a rural area said to not have access to shopping compared to 6% for those currently working/studying in an urban area. Similarly 34% of those currently working/studying in a rural area said to not have friends or family in the area compared to 16% for those currently working/studying in an urban area. (See further details annex Tables 224-243). Jan 2013 Bls. 45

8. Comments from participants 8.1 Intended career pathway Canada - among the Canadian participants 13 respondents commented to the question on intended career pathway. Main themes included, retirement (4), shift of current role- (shift to locum, shift to urban or rural practice, and shift to research n=6). Other comments included mix of leadership and clinical work, subspecialty training and compassionate care for patients. Greenland - among the Greenlandic participants 37 respondents commented to the question on intended career pathway. Main themes are moving on and moving back to Denmark. 5% expect to move back to Denmark. 4% will retire also in Denmark. 4% want to move on with their career in terms of advancing to leading positions or choosing further education. 3% want something entirely different as for example going into the flower business. 3% just want to see what happens and await opportunities that might open op on a wide range. These numbers portray a very well-known picture as Greenland hires a lot of medical staff at the age of retirement as well as Danish medical trainees who take part of their practice study in Greenland in order to get rural experience. Iceland - a total of 199 comments in the open question was received concerning intended career pathway. Many of the respondents were retired (11%) and thus no other intended career pathway. Other 11% want to move abroad and work within the health care settings. Further study was often mentioned or by 11% of respondents. A big group (12%) also commented on changing their work place and start doing something totally different then providing health care services. Some (85) wanted to move, either within the institution or moving to another health care institution, especially to urban areas. Some respondents (5%) commented on their wish to move to management role and another 5% commented on that they wanted to stop working. Only 1% commented on their intended career pathway within the research field and the same applies to teaching (1%). Rather big group was unsure of what they wanted to do while 5% commented on unchanged situation. Some miscellaneous comments were in 11% of cases as they did not fit into the picture. Ireland - within Ireland/Northern Ireland a total of 49 responses were received in the open question in regard to intended career pathway. Of the 49 responses, there were various statements made ranging from awaiting on opportunities to arise (n=12), unsure (n=4), emigration (n=4), remain in current role (n=5), develop in current role (n=4), taking on an education programme (n=2), relocation due to personal reasons etc. Jan 2013 Bls. 46

8.2 Ideal job Norway among the 163 Norwegian participants who commented on the question regarding the intended career pathway the largest group mentioned wanting to Change jobs (some added that they wish to change jobs to avoid shift work) (n=70). Others mentioned Continuing education (n=30), Remaining at current workplace or in current role (n=15), Retirement (n=13), Relocating (n=12) or heading into Research (n=5). Scotland 1 - among participants in Scotland 87 respondents commented on intended career pathway. Attainment of a new role was mentioned by 29 respondents, these included new role in development/promotion (n=15), management (n=5), commercial healthcare (n=3) and outside healthcare (n=2). Relocation was mentioned by 18 respondents and included relocation for Development/Promotion (n=10) and family, financial or other reasons (n=8). Retirement was mentioned by 8 respondents, others said to intend to remain in the current role (n=6) or mentioned getting a permanent contract (n=4). For 14 participants the intended career pathway was yet unsure. Scotland 2 - among the Highland participants, 55 respondents commented to the question on intended career pathway. This group included 8 who intended to retire, 4 who were emigrating and 11 who wanted to do further education. The remaining figure of this group were undecided. Sweden- among the Swedish participants, 52 respondents commented to the question on intended career pathway. Four main themes were discernible in the text responses. The theme development within the current role was mentioned by 35% of the respondents (n=18) and included mentions advancing within the current line of work, retirement (n=6), change of work location, role or profession (n=18). Among those mentioning change of work 5/9 said to be considering opportunities in other professions. Satisfaction in the current role was mentioned by 5 respondents. Other comments included unsure, work less and getting a permanent position Canada - among the Canadian participants 18 respondents commented to the question on ideal job. Main themes included work in a rural setting (n=7), mix of community and hospital setting (n=2), urban and rural practice (n=2) consulting work (n=2). Other comments included long-term and palliative care, politics and policy, public health, teaching and women s health in Third world (n=5). Greenland among the Greenlandic participants 27 respondents commented to the question on ideal job. To 3.5% of the respondents a completely different job is their Jan 2013 Bls. 47

ideal job. 3% already hold their ideal job position. Another 3% prefer a combined job that gives room for part time and a combination of several different themes of interest. 1.5% reply that optimizing their current work area on a national level would be the ideal job. 1% responded that leadership within the Greenlandic healthcare system would be ideal. 1% prefer field research as the ideal job and finally, 0.5% would like an ideal job as a consultant within the current work area. Iceland 373 comments were received in in response to ideal job from the Icelandic participants. The largest group said their ideal job was at private practise/ selfemployed (n=112). A fairly large group (n=50) said their ideal job would involve a combination of for example clinical work and research or teaching or a combination of rural and urban health care work. Another large group (n=45) said their ideal job was outside of health care. Other respondents mentioned satisfaction in current role (n=38), management (n=21), undecided (n=21), retirement (n=8), nursing home (n=8) or rehab (n=4). A fairly large group of responses were sorted as miscellaneous as they did not fit other identified themes (n=66) Ireland within Ireland/Northern Ireland there were 44 open responses and statements made varied from taking on research work, teaching, changing profession, private practice, primary care promotion remaining in current positions. Choices would depend upon the current occupation of the individuals. Norway among the 163 Norwegian participants who commented on the question regarding their ideal job some mentioned they would prefer to Remain in Current position (n=11), while others said they wanted to Leave the health care sector. Other comments included work in the Private sector (n=8), work with Research, also in combination with tuition (n= 6). Whereas others said their ideal job would involve an Administrative position (n=6), a Leader position (n=6), work in a Hospital (n=10) or Offshore (n=5) Scotland 1 In total 71 comments were received from participants in response to question on ideal job. Of these administration was mention by 18 respondents, (n=18), Primary health care (rural or urban n=7), Primary and hospital healthcare (n=6), hospital (rural or urban n=5), Public health (n=6), Community health and social care (n=4), Self-employed private practise (n=6), Retirement (n=1), not known or unspecified (n=19). Scotland 2 - In total 39 comments were received from participants in response to question on ideal job. Primary health care (rural or urban n=5), Community health and social care (n=7), Management or leader (n=4), In their current role (n=8), not known or unspecified (n=15). Jan 2013 Bls. 48

Sweden - 56 comments were received in in response to ideal job from the Swedish participants. Of these the most frequent theme mentioned change either of work or work place (n=27). Of the 27 mentioned job outside of health care. Other themes involved working in a private practise/self-employed, private company or occupational health services (n=9) teaching/development or research (n=8), satisfied in current role (n= 6) and other (including unsure n= 5). 8.3 General comments Canada - In total 16 participants from Canada responded in the general comment section. Comments included mentions of the need of better definition of rural (n=5), questionnaire poorly constructed (n=4), lack of human resources in hospitals (n=1), lack of social and cultural opportunities in rural areas (n=1), professional isolation (n=1), survey does not address issues to solve rural recruitment and retention of heath care professionals (n=1) and very useful questionnaire (n=1) Greenland among the Greenlandic participants 48 have responded in the general comment section. Most comments 20 out of the 48 concerned the quality of the survey. 11 of the 20 who responded to the survey found a large part of the questions to be irrelevant. The main reason mentioned was that they have retired from their former jobs and just had temporary contracts in Greenland. For these employees such as social and domestic support systems are quite insignificant issues. Another 8 found the questions imprecise including mentions of the need of better definition of rural and urban. Just 1 respondent mentioned that the survey is good. Isolation was the other main issue mentioned among the general comments. Isolation causes retention of health care professionals in extreme rural areas to be a serious challenge. 8 respondents mentioned social isolation as a problem. Travelling is expensive and it is unlikely that settlers get to see their family abroad (counting relatives in other parts of Greenland as well as relatives in other countries) very often. Also, cultural life and good schools are lacking. Language isolation and professional isolation is mentioned by 3. There is a lack of high qualified skills and competences. Incorrect and untimely monthly salary is also mentioned by 3 respondents as a problem. Another 2 respondents pointed to the lack of good leadership in the Greenlandic healthcare organization. Finally 1 respondent declared being happy working in Danish rural areas as well as Greenlandic rural areas. Iceland A total of 186 general comments on the survey was received from the Icelandic participants. General comments are 55 (29%) among other things explaining respondents view to their general situation. Comments on definition of urban/rural areas are 36 (19%). Many find it difficult to understand the possibilities Jan 2013 Bls. 49

offered in the questionnaire or make comments on what they think is urban or rural those seem to be coming from smaller communities and find them more urban than rural. Comments on work environment are 20 (11%). Mainly on difficulties related to work in rural areas. General comments on the structure of the questionnaire are 17 (9%) but comments relating to lack of flexibility in answering some of the questions are 17 (9%) e.g. those who are both working in urban and rural settings or working in public clinics and also with private practice, those who are on leave (maternity leave) and some find the questions more directed to those who are working in rural areas than urban. Comments on vague or unclear questions are 14 (8%) and those who are retired find it difficult to answer. Then there are 8 (4%) comments on the questionnaire being too long. Comments on poor remuneration are 5 (3%). Ireland - Of the 375 survey respondents in Ireland/Northern Ireland, only 45 provided a comment to this question. Of the 45 there were a number who indicated they felt the survey was too long, enquiring the purpose of the questionnaire, not enough opportunity to comment on each section or not easy to make it applicable to their workplace. There were other responders who thought this is a welcome initiative, feel unhappy in their work, mentioned the lack of a satisfactory transportation system, poor broadband along with other individual statements Norway - general comments from the Norwegian participants included complaints on questions and the target groups and included comments on poor, unclear and irrelevant questions (n=18), question not well suited for students ( n=6), unclear definition of urban /rural (n=8), and comments saying it was unclear if questionnaire also applied specialized nurses other than midwives (n=3). Other factors mentioned in this section were the importance of affordable housing and airline fares, importance of being able to travel south to visit family and dissatisfaction that locums get better deals than regular staff that have tough shift system. Scotland 1 - in all, 111 general comments were made on the survey from Western Iles participants and these included comments on working conditions in where lack of job security/opportunities, limited career progression, and lack of appreciation was mentioned. There were also a number of suggestions on how to tackles problems related to recruitment/retention such as improving relocation expenses, use technology for mentoring/developmental availability in remote areas, appropriate remuneration and implementation of exit interviews to find out why staff is leaving. Other comment were related to social conditions with mentions of limitation of options for shopping, broadband, entertainment/leisure activities, Jan 2013 Bls. 50

public transport and that not being fully included in the community (better shopping/trade services for locals vs non-locals ). Comments on the survey questions including definition of urban/rural, too few or ill-fitting response options and mentions on that the survey were aimed at clinical staff or did not apply for participant s specialty. In addition, others commented that the survey was too long, ill structured, vague, confusing or repetitive. Other participants commented on their own situation in terms of being content or wishing to return to the Western Iles. Scotland 2-90 general comments were made on the survey from the Highland participants. Social life was discussed as a major influencing factor (n=26). Other comments were job-related (n=38), targeted action for recruitment (n=6), interest in reading report (n=2), A number of participants commented on the poor quality of the questionnaire and missing out key questions (n=18). Sweden- in total 79 general comments on the survey was received from the Swedish participants. A large number of those mentioned difficulties in understanding or answering question (n=43). Other comment were job-related (n=9), discussed urban-rural definitions (n=8), commuting (n=6), housing (n=3), targeted action for recruitment (n=4), interest in reading report (n=2), service in rural areas (n=2) and childhood environment (n=1). Jan 2013 Bls. 51

9. Conclusions This reports summaries the assessment on motivating and demotivating factors affecting recruitment and retention of heath care workers at the present time among close to five thousand health professionals and health care under grate students in seven countries, Canada, Greenland, Iceland, Ireland, Norway, Scotland and Sweden. The study was conduct as an online survey during September 2012 to December 2012 and represent data collected in frame of work package 2 in the project Recruitment and Retention of Health care Providers in Remote Rural Areas. The majority of respondents in the study were female and had more than 15 years of work experience. Almost half of respondents were registered nurses while about 1/3 were medical doctors. Although half of the respondents said to have a rural background, the majority of survey participants were currently working or studying in urban areas. With increased age a greater proportion of participants lived in rural areas and a strong correlation between living in and working in rural areas was observed. The majority of survey participants currently working in rural areas worked in a health care community centre/primary care practise whereas most of respondents currently working in an urban area were working in a hospital. In general, there was good agreement among participants on what constituted the most important factor in terms of professional aspirations with respect to their current job and personal professional development, irrespective if the current work/study place was located in a rural or in an urban area. With increasing age (and among medical doctors), a greater proportion of participants said to intend to remain in their current professional role. A markedly greater proportion of respondents currently working or studying in rural area said to not have access to entertainment, shopping or close friends and relatives in the same area compared to those working in urban areas. Respondents working or studying in in rural areas were also more likely to be less satisfied over supply, diversity and quality of suitable leisure activities. Although a relatively smaller proportion of participants agreed to feel professionally, socially, culturally, geographically or religiously isolated, this was more common among respondents currently working in a rural area. It should be noted however, that there are considerable differences between on how respondents from different countries defines rural and urban. In this respect, more than 95 % of the Canadian respondents consider community sizes with populations of 5,000-9,999 as rural while 2/3 participants from Greenland consider such a population size as urban. There was also a marked difference with respect variability Jan 2013 Bls. 52

between countries in the proportion of participants who said to work or study in urban areas (ranging from 36% of respondents in Scotland to 90% of respondents in Iceland). The potential difference in the perception on what defines urban or rural areas was also raised in comment section of the survey by the participants themselves. In summary, this report contains an assessment of factors affecting recruitment and retention of heath care workers and will serve as baseline information for future comparisons. Furthermore the study will aid for better understanding of motivating and demotivating factors affecting recruitment and retention of health care professionals and will facilitate developments for sustainable and high quality health care workforce for remote rural areas. Jan 2013 Bls. 53