The influence of motivation in recruitment and retention of rural and remote allied health professionals : a literature review

Introduction: Recruitment and retention of allied health professionals (AHPs) to remote and rural Australia is challenging and correlates with poorer health status of remote and rural residents. While much has been written about the recruitment and retention problem, this study took a new approach by reviewing the literature describing the motivation of AHPs to work in remote and rural areas and then analyzing the findings from the perspective of motivation theory using Herzberg’s extrinsic and intrinsic classification. Intrinsic motivation incentives are known to contribute to job satisfaction and come from within the individual, for example the pleasure derived from autonomy or challenge at work. In contrast, extrinsic motivation incentives are provided by the job and include such factors as salary and professional development provisions. Extrinsic incentives are important because they prevent job dissatisfaction. Job satisfaction has been shown to be linked with increased retention. Method: Thirty-five articles, including 26 from Australia, met the inclusion criteria. The key findings related to motivation from each article are outlined and the results classified into the extrinsic–intrinsic framework. The incentives are then further analyzed as having a positive or a negative influence. Results: In total, 38 different incentives were described a total of 246 times. Of the total, almost half (n=115) comprised extrinsic incentives with a negative influence, with poor access to professional development, professional isolation and insufficient supervision the most frequently reported. Rural lifestyle and diverse caseloads were the most frequently mentioned positive extrinsic incentives,

Introduction: Recruitment and retention of allied health professionals (AHPs) to remote and rural Australia is challenging and correlates with poorer health status of remote and rural residents.While much has been written about the recruitment and retention problem, this study took a new approach by reviewing the literature describing the motivation of AHPs to work in remote and rural areas and then analyzing the findings from the perspective of motivation theory using Herzberg's extrinsic and intrinsic classification.Intrinsic motivation incentives are known to contribute to job satisfaction and come from within the individual, for example the pleasure derived from autonomy or challenge at work.In contrast, extrinsic motivation incentives are provided by the job and include such factors as salary and professional development provisions.Extrinsic incentives are important because they prevent job dissatisfaction.Job satisfaction has been shown to be linked with increased retention.Method: Thirty-five articles, including 26 from Australia, met the inclusion criteria.The key findings related to motivation from each article are outlined and the results classified into the extrinsic-intrinsic framework.The incentives are then further analyzed as having a positive or a negative influence.Results: In total, 38 different incentives were described a total of 246 times.Of the total, almost half (n=115) comprised extrinsic incentives with a negative influence, with poor access to professional development, professional isolation and insufficient supervision the most frequently reported.Rural lifestyle and diverse caseloads were the most frequently mentioned positive extrinsic incentives,

Introduction
The recruitment and retention of allied health professionals (AHPs) to remote and rural areas in Australia, and elsewhere in the world, has long been problematic [1][2][3] .Maldistribution of the health workforce has been widely acknowledged, with urban populations having greatest access to health care, including that provided by AHPs.Increasing remoteness correlates with increasing workforce shortages and a higher burden of disease [3][4][5][6][7] .The reasons professionals come, what makes them stay and the reason why they leave remote and rural areas has been the subject of discussion and debate in both the academic literature and government policy [2][3][4][5][8][9][10][11][12] .
This review analysed the literature describing AHP motivation to work or not work in remote and rural areas.Motivation is defined as the reasons, beyond personal traits, that drive an individual towards a goal 13 .In this article the 'individual' is an AHP and the 'goal' is working in remote or rural workplaces.The aims of this review were to address two research questions: (i) what does the literature describe as the incentives that motivate AHPs to work in remote and rural areas; and (ii) are these incentives classifiable into a framework that is useful in addressing the workforce maldistribution?An analysis of this type can assist in policy design and organisational strategies which focus on the recruitment and retention problem.This analysis is underpinned by Frederick Herzberg's seminal framework of motivation at work, which classified worker motivation into two types: intrinsic and extrinsic 14 .Herzberg's research provided insights into motivation that are integral to current understandings of job satisfaction, which is associated with workforce retention 15,16 .
Extrinsic motivation incentives are provided by the workplace.Examples include salary, work status and security, leave allowances, and professional development.These types of incentives have been termed 'hygiene factors' because they prevent job dissatisfaction 14 rather than providing job satisfaction.Perceived restriction of extrinsic incentives (eg inadequate salary for responsibilities expected) has been linked to reduced job satisfaction 14,17,18 .
Intrinsic motivation incentives are inherent in work, that is the pleasure derived from the work itself 19 .They make a person 'feel good' about their work and their performance of it.These incentives provide a reason above and beyond the extrinsic incentives to engage in the work and contribute directly to job satisfaction 14 .Examples include challenge, autonomy, and perceived significance of the work.
Studies of health professions, including nursing, medicine and allied health have confirmed the relative importance of intrinsic incentives over extrinsic incentives in providing job satisfaction 17,18,[20][21][22][23] .For example, Randolph in a study of 328 rehabilitation professionals in North America concluded that extrinsic incentives were weaker in significance for predicting job satisfaction and intent to stay compared with intrinsic incentives, such as professional growth and a work environment in line with personal values 18 .Likewise a study by Lyons of 787 American healthcare professionals found that three out of four of the top factors for predicting job satisfaction were intrinsic incentives, including 'worthwhile accomplishment and opportunities for growth and recognition' 17 .Kamien, in a longitudinal study of Australian rural medical workforce defined three incentives contributing to professional job satisfaction: variety in work, autonomy of practice and the feeling that one is doing an important job 16 .
For any individual at any point in time, there is a dynamic balance of extrinsic and intrinsic incentives.Unique environmental, professional and personal factors interact with motivation to impact job satisfaction and recruitment and retention outcomes 5,24- 29 .Age and experience interplay with background and overall goals.Younger professionals rank career opportunities (extrinsic) more highly than older professionals 30,31 .The intrinsic reward of job challenge and autonomy can offset the extrinsic disincentive of personal and professional isolation associated with remote and rural work 31,32 .Additionally, factors that operate as incentives for some may be viewed as disincentives by others (eg rural lifestyle) 33 .
The factors that motivate AHPs to work in remote and rural areas are of considerable interest to both service providers and policymakers because recruitment and retention of AHPs to these areas is problematic 11 .One model showed that the risk of an AHP leaving a remote or rural position is twice that of a nurse or doctor 11 .There is a body of descriptive research that has examined the contributors to recruitment and retention; however, almost no literature has looked at the motivation of remote and rural AHPs from the perspective of extrinsic and intrinsic motivation.This literature review examined the incentives affecting motivation in AHPs working in remote and rural areas, offering new approaches to improving recruitment and retention.In particular, it looked for the balance of extrinsic and intrinsic incentives and asked how this new insight can assist in the development of recruitment and retention strategies and practices.

Method
Literature was retrieved for this investigation (October 2010) using the PubMed and CINAHL electronic databases as well as Google Scholar (Fig1).Key words included allied health professional/personnel, motivation, job satisfaction, rural, remote, recruitment, retention, workforce, career decision, vocation, in addition to specific allied health professional titles (eg occupational therapist, audiologist).Variants on professional titles were used where appropriate (eg speech pathologist, speech-language pathologist, speech therapist).Snowballing techniques were then applied whereby the reference lists of retrieved publications were searched for other relevant citations.Initial inclusion criteria included Australian-based research studies or systematic reviews published between 1990 and October 2010; however, the search was broadened to include other English-language studies or reviews in developed countries.If studies clearly included AHPs plus other health professionals, they were included; however, articles specifically focussed only on doctors or nurses were excluded.Studies of AHP student perceptions of remote and rural work were included.
A variety of definitions for 'rural' and 'remote' was found in the retrieved literature so for the purposes of this article the terms are used in a common-sense fashion to refer to the range of communities beyond major metropolitan areas.Similarly, the term 'allied health' is one that currently has no agreed definition, however, is generally understood to be inclusive of health professionals with a tertiary qualification, eligible for registration with a recognised professional body or board, who 'apply their skills to restore optimal physical, sensory, psychological, cognitive and social function' (p4) 34 .This excludes health professionals with a specific medical or nursing qualification.Included allied health professions are listed (Table 1).

Results
The results of the search are detailed (Fig1).More than 1000 articles were retrieved initially by the first author; however, full papers merited scrutiny by all authors when they met the inclusion criteria.Thirty-five studies; 26 Australian, five Canadian, three American and one comparing American and Canadian AHPs, were included.When the article sought to answer research questions that were broader than the motivation of AHPs to work in remote and rural areas, only those findings specific to motivation have been included.The methodology in the eligible articles was predominantly survey or focus group studies using a mix of qualitative and quantitative analyses.An overview of each study is provided as are the major findings related to motivation (Table 2).
Australian research was most prominent in the retrieved articles.The reasons for this could include that Australia has a historical context rooted in the importance of rural areas.
Additionally it has the third lowest population density in the world (after Namibia and Mongolia; Canada is eighth, USA is 53rd and UK is ranked 161 of 193 countries counted) 35 , yet as a developed country Australia has the resources to invest in research capacity and infrastructure to address the very significant needs of its remote area populations.All studies reporting demographic characteristics had a predominance of Caucasian female respondents which reflects the feminised nature of the allied health workforce.Additionally respondents were largely trained in their country of residence, which reflects the current barriers to pathways for recognition of international allied health graduates.Some professions, particularly those with small workforces such as podiatry, were only represented in studies that included a range of allied health professions because there are comparatively few of these professionals working in remote areas.
The specific findings of each article were analysed using Herzberg's extrinsic and intrinsic classification.The results of this further analysis are shown graphically according to the number of articles reporting each extrinsic incentive (Fig2), and the number of articles reporting each intrinsic incentive(Fig3).The vertical axis in each figure presents the incentives reported in the articles while the horizontal axis shows the number of articles reporting each incentive.Note that the horizontal axis has a positive and negative side, depending on the influence of the incentive.An incentive could create a positive effect by its presence, for example 'family nearby'.Conversely an incentive could create a negative effect by its presence (eg 'large caseloads') or by its absence (eg 'lack of work resources').
Twenty different extrinsic and 18 different intrinsic incentives were mentioned a total of 246 times.Of these, a comparison of Figures 2 and 3 demonstrates that extrinsic factors with a negative influence (n=115) comprise almost half of all incentives mentioned, while intrinsic incentives with a negative effect are the least frequently reported (n=18).Incentives that influence positively were reported at similar frequencies for both extrinsic (n=54) and intrinsic (n=59) incentives.

Discussion
Individually each research article has a small sample size but combined the data represents strikingly similar views on remote and rural recruitment and retention incentives from more than 3000 AHPs.The factors described in the allied health literature are consistent with those described in literature relating to nurses, doctors and teachers in underserved areas 16,17,61 .

Investigated support, education and training needs
Incentives with a negative influence dominated findings with more extrinsic than intrinsic incentives highlighted Bent (1999)  [32]  Qualitative (semi-structured interviews) PT, Physiotherapists (Physical therapists in North America); SP, Speech pathologists (Speech-language pathologists in North America).

Extrinsic incentives or hygiene factors
Extrinsic incentives are provided by the job.In the literature reviewed, they included both tangible rewards such as salary and less tangible ones such as 'lack of community knowledge of role' (Fig2).The power of extrinsic rewards lies less in what the rewards provide and more in what they prevent.They act to prevent job dissatisfaction.The absence of adequate extrinsic rewards reduces job satisfaction; however, the presence of extrinsic incentives does not increase job satisfaction 14 .
Overall, the results in Figure 2 show extrinsic motivation incentives characterised by a negative influence, predominated in two ways.More disincentives were reported and more articles reported each disincentive compared with incentives characterised by a positive influence.Herzberg's hygiene theory, where lack of extrinsic reward reduces job satisfaction, flags the possibility that AHPs who work in remote and rural areas are likely to have reduced job satisfaction with correspondingly increased rates of turnover.This is supported by authors who demonstrated increased rate of turnover for AHPs in remote areas compared with other health professionals in remote areas 11,32 .
Many of the extrinsic incentives are linked.Poor access to professional development 8,28,41,48 and insufficient supervision 8,52 could both exacerbate the sense of professional isolation.For example, occupational therapists reported difficulty accessing feedback on their performance 45 .Services that implemented strategies to improve supervision and professional development opportunities reported positive outcomes 47,53 ; however, it should be noted that one study 62 failed to find a significant association between access to professional development and intention to stay.There were mixed findings on the financial implications of remote and rural work.Private practitioners tended to report a stronger financial motivation to work rurally, particularly pharmacists, physiotherapists and dentists 39,42,63 .Interestingly, a study of the Northern Territory (Australia) dental workforce reported that financial incentives did not have lasting effects for retention because dentists recruited on the basis of salary tended to be retained for 5 years or less 42 .In contrast, young graduates who believed their responsibilities were greater than their financial compensation were dissatisfied 31 .
A frequently mentioned positive extrinsic incentive for AHPs to work in rural or remote areas is the perception that these positions facilitate rapid development of professional and administrative skills due to the broad experience and diverse presenting caseloads 24,39,44 .New graduates find this particularly attractive as it provides a career fast-track, a growth experience, in order to secure a subsequent position in an urban area 31,54 .However, the resultant turnover disadvantages the region and has led to the labelling of remote and rural areas as 'professional nurseries' 64 .In contrast to the desirable career fast-track potential is the anxiety expressed by some AHPs over losing professional skills when working in an isolated remote or rural position 9,31 .Perceptions of metropolitan peers not respecting skills obtained in remote or rural practice were reported 57 but often found to be untrue when returning to urban positions 31 .Anxiety concerning the maintenance of professional skills is associated with frustration that specialisation and a career pathway for rural generalist clinical AHPs does not exist 44,55,56,60 .Creative professional development opportunities and two-way collaboration with metropolitan centres could assist; however, policies and strategies to fund and backfill positions during leave must be implemented 57 .Interestingly, a recent study on rural Canadian occupational therapists reported more reward than challenge in rural work and theorised that access to professional development and support using telehealth and other distance technologies may be making a positive difference 37 .
A number of extrinsic incentives were related to the characteristics of rural living.Rural lifestyle 24,48 , the presence of family locally 42,46 , and positive financial affordability make some rural areas more attractive than urban areas 24,50 .Conversely, it was clear that for some AHPs the cost of living and the cost of accessing professional and social networks are higher in remote and rural areas 32,45 .Thus personal views on rural living, desire to locate near to family and the financial implications of the particular remote or rural location are unique to individuals.Selection of rural-background students into training programs and adequate provision of work and educational opportunities in rural areas for extended families 48 could positively influence retention at critical life stage decision-points.
A large number of studies highlighted the stress resulting from managing large caseloads in remote areas 45,59 .In stark contrast only two studies reported manageable caseloads and concomitant increased job satisfaction 53,55 .Lack of locum support combined with long working hours 39,40 , lack of access to air travel 56 (which would reduce time required to travel to clients), excessive travel 8,44 as well as the idea that 'there is nobody else' (ie positions are left unfilled 32 ) add to the stress.
Overall, the studies demonstrated that hygiene factors or positive extrinsic incentives were lacking, underscoring the risk of continued high turnover of AHPs working in rural and remote areas, in part from reduced job satisfaction.

Intrinsic incentives
Intrinsic incentives are what makes a person feel good about engaging in their job 14,65 and contribute directly to job satisfaction.In the literature reviewed this included themes such as challenge and autonomy.A predominance of intrinsic incentives with a positive effect is shown (Fig2).
Autonomy was the most frequently mentioned intrinsic reward and is aligned with other literature 14,66 which emphasises the importance of autonomy in building motivation.Autonomy was valued in regard to decisionmaking about caseload management and schedules 39 when it allowed work to be structured in a way that suited the professional 45 , and because it allowed professionals to respond creatively to community needs rather than being locked into a bureaucratic system of service delivery 51 .
There was a strong theme of connectedness operating as an intrinsic incentive.While the presence of extended family enhanced connectedness to communities 24 , professionals also reported an emotional commitment to rural life 39 .Rural communities can enhance or reduce the motivation of AHPs to remain in their community by facilitating friendships and support networks 42 ; the isolation experienced by young professionals can be alleviated by access to peers 54 .
Educational 48 and employment provision 28 for the AHP's family also enhanced feelings of belonging.
Challenge, as an intrinsic motivator, exists on a continuum.Intrinsic motivation will flourish when the level of challenge contributes to a sense of achievement and fulfilment but does not overwhelm 67 .The AHPs who felt they could not meet the needs of the community reported feeling overwhelmed 56 .For example, new graduates enjoyed the challenge of diverse responsibilities found in remote and rural work and felt that the long-term career benefits outweighed the disadvantages 54 , while experienced professionals looking for a new challenge were attracted by the novelty of working with Indigenous communities 32 .The drawback to this finding is that novelty alone appears insufficient to influence long-term retention.Hall et al demonstrated statistically that retention of dentists in remote areas who were motivated by the novelty of cultural challenge was 5 years or less 42 .Workplaces seeking to reduce high recruitment costs 11 should look beyond novelty as an inducement and ensure that new professionals are well oriented and supported for the challenges they will encounter.
Retention is negatively impacted when a professional does not feel their work is significant or respected.Therefore it is of concern that some studies found AHPs felt their work was not valued by the community 50 .This was more likely to be an issue for professionals such as occupational therapists whose role can be diverse.Supportive management practices such as timely recruitment to vacancies 32 , locum provision, teamwork 54 and a critical mass of professionals 50 , strong liaison with other local health providers and engagement with the community 51 to ascertain their needs could alleviate this feeling.Furthermore, when positions are vacant for long periods, as is often the case in remote areas, it is much harder for incoming professionals to build networks and establish credibility and trust 31 .

Job satisfaction and the imbalance of extrinsic and intrinsic incentives
The findings of this literature review have demonstrated that the extrinsic/intrinsic classification is a useful framework from which to consider the motivation of AHPs to work in remote and rural areas.Figures 2 and 3 demonstrate the overwhelming predominance of extrinsic disincentives compared with all other incentives.Given Herzberg's contention that extrinsic disincentives reduce job dissatisfaction, the burden of negative extrinsic factors would suggest the likelihood of a dissatisfied workforce.
Few studies formally assessed job satisfaction.Those that did frequently commented that AHPs were dissatisfied with aspects such as conditions of employment 31 .Despite these frustrations, summary comments often referred to AHPs being satisfied with remote and rural work 58 .These kinds of statements are likely to refer to the intrinsic factors which are providing a measure of satisfaction but cannot fully mediate the extrinsic disincentives.Congruent with literature on urban AHPs 68 and nursing 69 it could be hypothesized that high turnover is related to job dissatisfaction from extrinsic incentives.

Policy implications
Evidence from the medical workforce suggests that policy aimed at addressing the extrinsic disincentives may make a difference to AHP workforce recruitment and retention.Australian government policy provides significant extrinsic incentives to the rural and remote medical workforce as a successful strategy to reduce shortages 5 , with the literature showing remote and rural doctors to also have a lower risk of turnover than AHPs 11 .Finally, the literature of GP job satisfaction demonstrates reasonable job satisfaction regardless of location 70 .Given the complementary relationship between extrinsic and intrinsic incentives, fortifying existing intrinsic incentives might provide a parallel strategy to addressing recruitment and retention challenges.

Limitations and further directions
This analysis was unable to capture data on the interaction between incentives and life stage because this workforce demographic was not always examined in the literature.It appears that new graduates are more willing to cope with an absence of extrinsic reward because of the potential benefits they gain.Looking at life stage could be an important avenue for future research 71 with the potential to reduce retention problems further by implementing life stage appropriate strategies.

Conclusion
Extrinsic motivation factors for remote and rural AHPs are clearly deficient.Recruitment and retention strategies must address this need urgently.While it is clear that the intrinsic incentives which contribute to job satisfaction are present they appear insufficient to mediate for the burden of extrinsic disincentives which contribute to excessively high turnover.The absence of positive extrinsic incentives is eroding job satisfaction that could improve retention.As demonstrated in the literature 53,57 , remote and rural healthcare organisations that encourage and foster the fulfilment of the intrinsic motivation of a professional, as well as providing the extrinsic elements to motivation have the most potential to recruit and then enhance the longevity of the AHP in that position.
working in rural and remote Australia.

Figure 2 :
Figure 2: Number of articles reporting each extrinsic incentive.

Figure 3 :
Figure 3: Number of articles reporting each intrinsic incentive.

Table 1 :
Allied health professions eligible for inclusion in this study