‘Get away from it all’ or ‘Too good to be true?’: a qualitative exploration of job advertisements for remote and rural posts

Introduction

Research consistently demonstrates that people living in remote and rural areas face significant challenges in accessing quality health care, resulting in adverse health outcomes^1-4. These healthcare access barriers often compound existing inequalities such as low income, inadequate transport, social isolation, comorbidities and overall poor health, further exacerbating health disparities⁵.

Recruitment and retention of the healthcare workforce is crucial to maintaining access to services and provision of care, but these are ongoing challenges for health services both in the UK National Health Service (NHS) and globally. For example, there are proportionately fewer NHS staff per head of population in rural areas of the UK with up to 45% fewer NHS workers per head in the most rural areas⁶. Unfilled vacancies put additional pressures on already-stretched remote and rural services.

We know from systematic reviews of the international literature that many recruitment and retention strategies are based on little definitive evidence^7-12. Being born or brought up in a rural area remains the strongest indicator of career intention, and evidence has shown that extensive rural placements during training may also have an impact. However, combining several strategies is most likely to be effective¹³.

Several studies have measured features of the community that are associated with better or worse recruitment/retention, a notion that could be termed ‘community attractiveness’. The Community Apgar Questionnaire¹⁴ was developed in rural Idaho to measure the assets and capabilities of rural communities related to physician recruitment and retention. It was designed to identify which factors are most important for a community with limited available resources to address. This includes place-related features such as recreational opportunities, spousal satisfaction, schools, shopping, housing, social networks and general perception of the community. All these elements relate to the concept of Asset-Based Community Development (ABCD), which aims to support communities to make best use of the assets available to them to improve their situation¹⁵. These include individual skills, community organisations, social networks and the natural environment.

Closely linked to the importance of community is a broader literature, particularly from rural studies, about migration and sense of place^16,17. This body of work does not feature routinely in applied research on recruitment and retention, which has tended to focus chiefly on job characteristics, professional training, financial incentives, and an individual’s professional needs and aspirations.

A migration lens¹⁸ shifts the focus from the job to the person, the family and the place; elsewhere we have argued that reconceptualising ‘recruitment and retention’ as ‘moving and staying’ better encapsulates this more holistic understanding of what motivates people to take up a post in a remote or rural area, and what makes them stay once they get there¹⁹.

As part of a wider study of place-based community-led initiatives to attract healthcare staff to remote and rural areas, we decided to examine how NHS job advertisements represent the community to which they are recruiting, drawing on ABCD to focus on which social and professional community assets are given prominence, and how.

Methods

Data collection

In total, 270 job advertisements for posts in remote and rural areas of the UK were collected between July and December 2022, from a monthly search of three sources: the British Medical Journal (BMJ) job advertisement site https://www.bmj.com/careers (covering GPs and secondary care doctors across the UK); the NHS Scotland GP job site https://www.gpjobs.scot; and the NHS Scotland jobs site https://jobs.scot.nhs.uk (covering secondary care doctors, dentists, nurses, midwives, allied health and care professionals across Scotland only).

To manage the volume of data, the search for non-medical positions was restricted to Scotland. Despite this limitation, non-medical roles constituted 43% of the collected advertisements.

Advertisements for posts that occurred in more than one search were generally excluded, unless the content was substantially different. Identical advertisements that appeared in successive months were excluded; some that were readvertised after a gap were included again. (It is worth noting that some still gave the old closing date and were clearly repeat advertisements.) Some gave no closing date, leaving the vacancy open until an appointment was made. One English county had an ongoing open advertisement trying to recruit GPs to the area, as well as for specific practice vacancies. This open advertisement was included only once.

Deciding which advertisements to include required some geographical interpretation; an advert might describe a practice as ‘rural’ when it was within easy reach of a major population centre. However, this was not intended to be an exhaustive quantitative analysis. Rather, the aim was to identify an information-rich purposive sample to illuminate how rural and remote communities are depicted to potential job applicants, what is highlighted and what is sometimes absent²⁰. Advertisements were therefore assessed for their relevance to this purpose.

We then contacted named recruitment contacts from all the advertisements collected, where possible, to ask how many applications were received and whether an appointment had been made.

Analysis

Informed by the ABCD lens, we analysed job advertisements using a thematic framework analysis approach to identify the different assets that advertisements highlighted, use (or not) of visual media and how advertisers ordered information about the job versus the community as a place to live.

Our framework was both deductive, in searching for assets we anticipated would be important (eg transport links, the natural environment, schools and housing), and inductive, as the analysis identified additional features (such as tone and humour). The framework was applied to the dataset by one researcher (ZS), in regular discussion with the wider team.

Responses from advertisers contacted were added to the framework, including free text about their experiences of trying to recruit.

Ethics approval

Ethics approval was obtained from the University of Aberdeen Medical School Ethical Review Board (SERB/2021/10/2186).

Results

The advertisements collected are shown by job type and location in Table 1.

Advertisements ranged from a couple of short paragraphs of text describing the post, with perhaps (although not always) a few details about the location, to lengthy and elaborate descriptions of both the post and the local community, sometimes with photographs, links to further information and videos about the community.

The templates offered to advertisers within the three platforms were quite different. Although not featuring any photographs, on the NHS Scotland GP Jobs site a street map of the location was usually included along with a descriptor such as ‘remote rural’, ‘accessible rural’ or ‘rural small town’, adopting standard Scottish Government definitions²¹. Some practices worked around this lack of visual information by incorporating links to a YouTube video or to the practice Facebook page.

The wider NHS Scotland Jobs site regularly included photos, drawn from a bank of stock photos consisting mostly of clinical staff at work, interacting with patients. Again, however, some advertisements gave links to supplementary information and videos.

The BMJ Jobs site offered advertisers the opportunity to include photographs within the main advertisement (although this feature was not always used). BMJ advertisements also included tabs for both ‘job details’ and ‘company’, allowing advertisers to add considerable additional information about both job and place, including pictures of landscape, local buildings and NHS facilities. It is worth noting that platforms that are free to use may not offer as much flexibility as those for which advertisers have to pay.

The NHS Scotland GP Jobs site refers advertisers to a guide produced by the Scottish Rural Medicine Collaborative (https://www.recruitmentsupport.scot.nhs.uk/advertising), which, while not mentioning photos, highlights the importance of using of links to video content and visuals.

In our thematic framework analysis of the advertisements, informed by the ABCD lens, we focused on how the jobs were presented and which community ‘assets’ were represented, and covered the following areas:

• presentation of job and place
• landscape and natural environment
• outdoor pursuits
• photos and videos
• connectivity
• family, schools, housing
• culture
• humour and tone
• nature of team and job
• other incentives.

Presentation of job and place

‘Include some information about the local community and the rural environment but do this after you’ve described the job. You are advertising a job – tell them about the job!’ This is the recommendation from the Scottish Rural Medicine Collaborative.

Box 1 illustrates two contrasting examples. The first, from Somerset, begins with information about place, quality of life, outdoor pursuits, transport and schools, before describing the job and the team. In contrast, although the second example from Jersey also mentions place early on, this is confined to a single paragraph. Of note, the very first point is directly about the job and the expertise the practice is seeking.

In common with many advertisements, these tried to emphasise that candidates can experience ‘the best of both worlds’ – by, for example, pairing information about local quality of life with transport connections to bigger places and expecting candidates to be hardworking but also offering a good work–life balance. (Some other advertisements paired somewhat paradoxical terms such as ‘modern’ or ‘forward thinking’ with ‘traditional’.)

Many of the advertisements in our sample placed early emphasis on ‘why here’ (i.e. the place) rather than ‘why this job’. One could argue that the difficulty for advertisers is anticipating how their advertisement will be received by different audiences. Perhaps healthcare professionals who are already open to the idea of a rural job or have not thought about it one way or the other might find the promotion of place more attractive than a description of job tasks. Potentially an approach such as the second example in Box 1 covers both bases, with concise information about the job but quickly followed by a sense of place and lifestyle.

Other job advertisements focused at length on the nature of the job first; of these, some seemed to give equal weight to information about place, while others covered it only briefly. One BMJ advertisement, for a salaried part-time GP in rural Wiltshire, included just this one sentence about place: ‘We are an easy commute from Bath with potential for a perfect blend of city and country life’.

A few advertisements did not mention anything about place. More commonly (but not exclusively) these tended to be for nursing, midwifery or allied health professional roles. It could be that NHS recruiters expect the applicant pool for such posts to live locally already, in which case they would need less persuasion about the attractiveness of the place. We also found medical examples including advertisements for a surgical research fellow in Scotland and a salaried GP in rural Wales with no mention of place, and a consultant anaesthetist advertisement in Scotland in which place was relegated briefly to a second page.

Landscape and natural environment

We found that the beauty of the local environment was one of the most obvious assets promoted. Advertisements commonly conjured up images of mountains, sea, beaches, forest and open country, wildflower meadows and opportunities to see wildlife. However, the extent of description varied widely. Often comments about landscape were embedded in a list of multiple assets such as the example in Box 2.

Outdoor pursuits

Intricately linked to the natural environment is the opportunity for an outdoor lifestyle. Advertisements referred variously to walking, hill-walking and climbing, mountain biking and cycling, skiing and snowboarding, golf, fishing, wild swimming, surfing, kayaking/canoeing, sailing, bird-watching, dog-walking, safe outdoor play for children and just being ‘in nature’. These were often represented in accompanying videos. In a YouTube video transcript, a GP already working in the area commented:

I think if you like outdoor life and outdoor living, then it’s really good. So I’m quite happy running by the hills, walking around with a dog, which is great. I think if you didn’t have any outdoor pastimes or anything like that it might be fairly isolated.

Photos and videos

Not all advertisements included photos. Non-generic photos, where included, ranged from pictures of NHS premises – not always very appealing – to pictures of scenery, seaside and harbours, village scenes, people taking part in outdoor pursuits, attractive local buildings and historic monuments (such as churches and Hadrian’s Wall). Some aimed for a level of artistic composition such as the sun setting over the sea or snowy mountaintops.

Videos were sometimes specifically created for the job in question or advertisements included generic videos used whenever that location was trying to recruit. Some were NHS produced and some community produced. These commonly featured a mixture of NHS staff interviews or pieces to camera talking about the job and the team, footage of NHS facilities and people at work, and images of local landscape and attractions.

Connectivity

When thinking about if and how advertisements covered the issue of connectivity, we looked for detail about transport options, ease of accessibility and journey times to nearby destinations, as well as digital connectivity (eg wi-fi).

Many advertisements emphasised their close proximity to towns and cities. One advertisement for a GP on the west coast of Scotland mentioned being ‘90 miles from Glasgow, 35 miles from Oban’. It is worth noting that to get to Oban from this location there is only one single carriageway road, which map apps suggest can take over an hour to drive, while the nearest station with trains to Glasgow is also over an hour’s drive. It is understandable that advertisers want to emphasis connectivity rather than lack of it. A number of Scottish island advertisements referred to regular ferry services, but unsurprisingly did not mention that these may not run every day of the week or the possibility of cancellation in bad weather. We recognise that the purpose of an advertisement is to encourage interest rather than to dissuade, but there is a balance to be struck. As one advertiser pointed out to us (see ‘Recruitment outcomes’ below) there is a risk that time may be wasted by both applicants and recruiters if unrealistic expectations are raised.

Occasionally advertisements suggested there was actually no need to live in the location, noting that living in a nearby city and commuting would be possible. But most seemed to strike a balance between the ‘get away from it all’ rural idyll and access to more urban life.

While access to fibre and radio broadband has increased rapidly in remote areas, some areas remain underserved. Digital connectivity might include professional aspects such as telemedicine links to major hospitals and virtual appointment systems, but also how/whether the local community as a whole had good digital services. However, we found no mention in our sample of the quality of local broadband.

Family, schools and housing

We know from previous research that moving to a remote area can be a whole family decision. The extent to which advertisers reflected this in their materials varied.

The excerpt in Box 3 from Royal Cornwall Hospitals Trust offers an illustration of how assets relevant to wider family life might be presented.

We found that quality of life for children a was a common theme. Schools featured prominently, with some advertisements referring to the Office for Standards in Education, Children’s Services and Skills inspection results, and some also mentioning local private schooling. These family factors are important for not just recruitment but also retention¹⁹.

The advertisement in Box 3 was highly unusual in suggesting the employer might also be able to identify jobs that partners could apply for.

Housing is another important factor in healthcare workers’ decision-making. However, as with employment opportunities for partners, we found (perhaps surprisingly) that housing was rarely mentioned. Occasionally, advertisements mentioned that the area had ‘reasonable property prices’, ‘a wide diversity of housing’ or ‘a reputation for excellent properties’, but almost nothing about support to find housing. One advertisement for a salaried GP in Orkney stated that accommodation was provided (but with no further detail); this was a role for part of the year only (enabling people to work elsewhere for the rest of the year), making accommodation particularly important. Another advertisement for a mental health nurse mentioned ‘newly refurbished accommodation to rent’.

Culture

We interpreted ‘culture’ broadly and looked for examples in advertisements of ‘assets’ such as theatre, cinema, restaurants, history, museums and galleries, shops and local tourist attractions. An advertisement for a GP in Kilcreggan, Argyll, was one of the more extensive examples:

Kilcreggan has its own pharmacy, cafe, small shop and a great pub which serves fantastic food, a supermarket is available in nearby Rosneath. The area also has the well rated Knockderry Hotel. Garelochhead at the top of the Peninsula has a petrol station and cafe. Helensburgh (15 miles away) has two supermarkets and a wide range of independent shops/cafes/restaurants and a cinema.

As in the case of Kilcreggan, advertisements often alluded to cultural assets being available within travelling distance rather than in the immediate locality. One advertisement for a GP in Somerset talked of the ‘irrepressible creative spirit’ of Bristol (19 miles (30.6 km) away) and its ‘world famous balloon festival’.

Humour and tone

While most of our sample of advertisements could not be described as funny, some used elements of humour. One example was for a GP in Dumfries and Galloway, with the opening line ‘Father Ted needs a Dougal, Jack has left Craggie Island!!’ The advertisement then goes on to explain that ‘We are looking for a GP to join our small friendly & supportive team, due to a partner’s retirement’. This is drawing on a popular 1990s UK comedy sitcom and so might be difficult to understand for younger prospective applicants.

Another advertisement, from rural Wales, used humour frequently, in an unusually long advertisement (running to five pages in a Word document). This included statements such as ‘it is sometimes rather a relief to be out visiting as the journeys are so beautiful’, ‘while a cow or two might hold you up briefly queues are very rare and usually commented on in Facebook’ and (perhaps in questionable taste) ‘most of us work part time and all have special interests (rather than special needs!)’.

Most other examples of humour were brief and straightforward – for example praising the quality of the coffee available at practice meetings or joking about the weather on the west coast of Scotland.

Apart from humour, other aspects of tone were noted, ranging from strictly factual descriptions of the job to romantic accounts of a new lifestyle: ‘Do you ever dream of driving to work on quiet roads, alongside a beautiful Scottish sea loch?’

The five-page Welsh example mentioned earlier took a conversational tone in describing in some detail the relationships within the practice, and a close relationship with the local community (as shown in the excerpts in Box 4).

The advertisement in Box 4 seemed to be trying to engage with potential applicants at an emotional level and gives a strong sense of what it would be like to live and work there. However, the ‘too good to be true?’ heading is notable in the sense that perhaps there is a risk in trying to oversell the practice and the place; of sounding a little desperate.

Nature of team and job

The excerpt in Box 4 is one of the more extreme examples of how advertisers sought to portray the nature of the working environment as an asset. However, other advertisements also frequently mentioned the ways that remote and rural practice differs from urban practice, and how small teams work and live closely together, and often socialise together. Work–life balance, strong team cohesion, continuity of care and the opportunity to practice in a more holistic way were all commonly mentioned. One job advertisement in rural Scotland described the role as a ‘relatively stress-free job with plenty of variety’, for example.

Perhaps unsurprisingly the potential drawbacks of remote practice – for example the stress of lone working, the difficulty of getting cover for time off, or feeling professionally or socially isolated¹⁹ – rarely featured or were given a positive spin, as shown in these two advertisements:

Spice up your regular GP skills with the challenges of pre-hospital emergency care whilst waiting for helicopter evacuation. Emergency care training, with standardised equipment and protocols is provided.

The role of the Advanced Practitioner is dynamic and it is essential that skills are maintained in order to offer a safe and sustainable service to the community, as a consequence there will be opportunities to work in other locations and learn new skills.

Of note was how often we saw claims to be a ‘forward-thinking’ practice; for example, ‘we are a dynamic and forward-thinking team with a wealth of clinical and leadership experience’.

Occasionally, a practice would instead describe itself as ‘traditional’ (eg ‘we are a small, semi-rural practice with a traditional family doctor approach’), but the exact phrase ‘forward-thinking’ appeared repeatedly across our sample. One could argue that advertisers face a dilemma of wanting to appear modern, up-to-date and innovative, while at the same time wanting to appeal to those looking for an opportunity to get back to greater generalism and continuity of care.

Other incentives

In addition to the range of community ‘assets’ across our sample, we found that many advertisements described a range of other incentives relating to the job itself. Sometimes these were financial (eg funded relocation schemes, financial ‘Golden Hellos’, competitive salaries, medical defence subscriptions, annual General Medical Council fees, free memberships to various reward and benefit platforms such as Perkbox, excellent pensions) whereas others related more to workload (eg no out-of-hours/weekend work, protected training time, reduced administrative burden, low patient-to-doctor ratio, paid sabbatical, generous annual leave package). Other job-related incentives included individual mentoring, car lease and cycle-to-work schemes, and the opportunity to work with the local mountain rescue team.

Recruitment outcomes

Where we had access to an email contact, we attempted to contact job advertisers to ask whether an appointment was made and how many applicants were shortlisted. Emails were sent to 189 advertisers, and we received 45 responses. The results were disappointing, both in terms of the number of responses received and the story they told.

Of the 45 responses, only 18 stated that an appointment had been made as a direct result of the advertisement. Of these, two were GPs and the rest were allied health professionals. While a few appeared to have been straightforward appointments, replies sometimes indicated a more complex story. In one instance, the appointment did not work out because the person was less experienced than expected, and the postholder was soon to be leaving after a short period in post. Several respondents highlighted lack of experience among applicants as a concern.

Four advertisers told us that, after many unsuccessful attempts, they eventually managed to recruit a GP through their own networking, by persuading a locum or a trainee to stay on, using word of mouth locally, or using the services of a headhunter. There was evidence in advertisers’ responses that people recruited had not necessarily been looking for a job until the vacancy was brought to their attention

Of the remaining 23 replies, five told us that they did not know the outcome or that the vacancy remained unfilled. Eleven reported having received no applications, and two said they had applicants but none were suitable for shortlisting. Three had shortlisted but were not appointed, and a further two reported that the only appointable candidate withdrew.

In their responses, some commented on the ongoing challenges around recruitment and retention, and their frustration at the lack of interest in their job advertisements. One responder, who told us they had been involved in various recruitment drives, said that while these can be helpful for reaching a wide audience, they can sometimes overstate the idyllic quality of life in a small community, and mislead applicants.

Discussion

To our knowledge, this is the first study to examine using a theoretical lens how NHS job advertisements represent the community to which they are recruiting. A systematic search of PubMed demonstrated that literature around NHS job advertisements is almost entirely focused on analysing the content of jobs and the emergence or decline of specific professional roles. While this was a study of job advertisements for the UK’s NHS, the findings are likely to be transferable to other countries and healthcare systems with problems recruiting to remote and rural areas.

Summary of main findings

Drawing on an asset-based community development approach¹⁵, we found that while many advertisements included plenty of detailed information about the community and the lifestyle, other places may not be realising the full potential of local assets. The asset headings identified in this paper and in the Community Apgar Questionnaire could be used as a guide for advertisers to consider when preparing an advertisement¹⁴. One simple change would be to provide more visual information, either in the advertisement itself or – if that is too costly – in a linked website or document. There were several examples of material that could be re-used for different vacancies.

It should be noted that asset-based community development is not without its critics. It has been argued that it risks placing too great a burden on individuals and communities, rather than focusing on the actions or inaction of government and public organisations, which may have weakened (in this case rural) communities or failed to recognise their needs²². Asset-based approaches may reinforce existing inequalities between already underserved areas, and not all communities will be able to point to assets such as a beautiful natural environment or good local facilities. Nonetheless, making the most of available assets in recruitment campaigns makes sense.

It has been argued that the twin aims of advertising – to inform and to persuade – are not of equal importance, and that persuasion is the primary goal²³. Unsurprisingly, most advertisers sought to present an attractive picture of the area and the job. Examples of realism about the possible drawbacks of living and working in rural and remote areas were rare. Over-emphasis of the ‘rural idyll’ could have unintended consequences, encouraging people to apply without fully realising what life will be like, as the imagined reality of living in a rural place can often be very different to the reality of actually living there^24-26. However, creating an effective sales pitch without exaggerating or misleading is hard to achieve.

The decision about how much attention to give to place versus job characteristics is another balancing act for advertisers. Findings from our previous research with doctors working in remote and rural posts suggests that place is a very important influence on decision-making, and that family needs and preferences for a place to live are crucial^19,26. Of course, the job is also important, but advertisements that make little or no mention of place could be missing a potential audience. Participants often spoke to older campaigns and putting job advertisements in social media groups for outdoor activities (such as cycling/mountain biking, hill walking, water sports) to try to capture people with the job skills and place-related interests.

Another balancing act for advertisers is getting the tone right while accepting that different styles of advertisement will be more, or less, appealing to different people.

Advertisements have been described as ‘attention-seeking devices’²⁷ and it has been argued that ‘advertising often finds itself in complex situations in which modest advertisements risk being left unattended, whilst the bold or perplexing might be disliked or misunderstood altogether’²⁸. While careful use of humour may help an advertisement stand out, advertisers should be alert to the danger of it becoming offputting. Similarly, enthusiasm for place is helpful but can risk sounding too pleading, which may deter applicants.

Feedback from advertisers has also suggested that those recruiting to rural and remote posts may need to proactively seek connections with potential applicants rather than hoping that the advertisement alone will be enough to find them.

The experience of advertisers suggests that recruiting through informal local networks – encouraging locums or trainees to consider staying on – may sometimes work better than formal advertising. This speaks to the value of training placements such as the Scottish Rural Training Fellowships in General Practice as a means to give people a taste of rural and remote life and work, and recruiting students from rural areas, ensuring their perceptions are grounded in reality, which is already well attested in research evidence²⁹.

This analysis is part of a wider study drawing on case studies in Scotland and England, exploring how various rural communities have become involved in recruitment and retention, developing novel forms of advertising, driving creative social media campaigns, and using print and broadcast news to attract staff to their area. These case studies have shown that advertising is just one component of active recruitment. Our findings from this broader work are in press³⁰.

Conclusion

There is evidence from these results that local place-based assets are not always featured as strongly or as visually as they could be in advertisements for remote and rural healthcare jobs. Our analysis of advertiser responses cannot demonstrate conclusively to what extent the nature of the advertisement was a decisive factor in recruiting or not recruiting. However, the number of responses reporting that no-one had been recruited or had even applied raises concerns about the amount of NHS investment in advertising. To our knowledge, there has not been a cost-effectiveness analysis of different styles of advertisement and different advertising outlets, and how these impact on outcomes. When so much is spent on repeated and sometimes fruitless advertising, this could be a valuable piece of health economics research to take forward.

Acknowledgements

We would like to thank NHS staff who responded to our request for information about the outcome of their advertisement. We would also like to thank members of our public advisory group for contributing their reflections throughout the broader study to which this article relates, and for supporting analysis. The group was formed of our two public co-investigators, Lorraine Angell and Topher Dawson; David Green (public member of the Study Steering Committee); Stewart Manning (retired GP); and Caron Jenkins (Professional Engagement Manager, Versus Arthritis, Scotland).

Funding

This study was funded by the NIHR Health and Social Care Delivery Research Programme (133888).

Conflicts of interest

Louise Locock reports past membership of the National Institute for Health and Care Research Health and Social Care Delivery Research Programme funding committee (membership ceased in 2019). Louise Locock and Andrew Maclaren report travel and accommodation support from the University of Central Lancashire for attending the annual conference of National Centre for Remote and Rural Medicine, and from the University of Lancaster for a workshop on medical education.

Disclaimer

The views expressed are those of the authors and not necessarily those of the National Institute for Health and Care Research or the Department of Health and Social Care. During the period of the study, the Health Services Research Unit (now the Aberdeen Centre for Evaluation) and the Health Economics Research Unit were core funded by the Chief Scientist Office of the Scottish Government Health and Social Care Directorate, which provided salary support for Louise Locock, Diane Skåtun and Verity Watson.