What influences nurses ’ decisions to work in rural and remote settings ? A systematic review and meta-synthesis of qualitative research

Introduction: Due to global nursing shortages, recruitment and retention of nurses is a major international concern, exacerbated in Rural and Remote Health rrh.org.au James Cook University ISSN 1445-6354


Introduction
In the context of global nursing shortages, recruitment and retention of nurses is an increasingly important challenge for the sustainability of healthcare delivery . Failure to recruit and retain nurses in rural and remote settings is a particularly acute problem . Nurse-to-population ratios are significantly lower in rural and remote areas, further exacerbating the problem . Nurse vacancies are anticipated to accelerate over the next decade as more of the workforce retires . Rural nursing practice has been defined as a unique, demanding and challenging speciality requiring specific personal qualities such as flexibility, versatility and adaptability . The characteristics of rural nursing include the need for rural nurses to assume the role of expert generalist and function as a jack-of-all-trades whilst working in a broad spectrum of clinical settings and performing many diverse tasks .
Despite the complexity of factors that influence nurses' decisions to work in rural or remote areas, much of the research to date has focused on specific factors in isolation. The purpose of this article is to systematically review existing literature on nurses' experiences to explore the influences on nurses' decision making to work in rural and remote areas. By doing so, findings from this study will inform strategies to improve recruitment and retention of nurses in rural and remote settings.

Defining 'rural' and 'rural nursing'
The literature is replete with definitions of rural nursing. The word 'rural' often conjures up images of the idyllic life in the country .
'Rural' is described as a vague and ambiguous term signifying many things to many people, such as agricultural landscapes, isolation, small towns and low population density . The literature categorises 'rural' using a range of pre-assigned characteristics including land use, population density, demographic structure, environmental characteristics, population characteristics, nonmetropolitan area and commuting patterns . The variation in definitions of 'rural' has important methodological implications such as assuring the validity, reliability and utility of research .
Definitional complexity around 'rural' also impacts understandings of rural nursing .
Rural nursing is defined by some as 'the provision of health care by professional nurses to persons living in sparsely populated areas' . Although there is debate around whether any difference exists between nursing practices in rural and urban health care facilities , some common features of rural nursing predominate.
The term 'expert generalist' is often used to describe rural nursing, with suggestions that rural nurses need to be a 'jack-of-all-trades and master of many' . Rural nursing is conceptualised as being a 'long way from anywhere and pretty close to nowhere, being independent or perhaps just being alone', and the challenges are

Existing evidence
Much of the recent research in rural and remote nursing has used quantitative designs and has been undertaken in Australia using large online survey repositories . These studies have investigated connections between personality and career choice, and they highlight that persistence, self-directedness, cooperativeness and reward dependence are congruent with the professions' requirements. Results conclude that individuals have a unique combination of traits that make them who they are, and that recruitment and retention policy should not adopt a 'one size fits all' approach . Myriad demographic, developmental and environmental factors influence an individual's life and work choices and their psychological profile, which raises a question about whether individuals with the observed temperament and traits are attracted to nursing in rural areas, or whether it is more likely that individuals develop certain character traits as a product of their rural experience and training .
There has been a tendency to consider rural and remote nursing through cross-sectional studies rather than longitudinally, which would explore a more informed understanding of rural practitioners' decisions-in-the-making. For example, the 'rural pipeline' describes the passage of medical students from the point of developing their aspiration for a career in medicine, through to retaining general practitioners (GPs) in rural locations, while highlighting key stages in between . This includes how individuals construct their career choice based on their personal identity and how an individual's attachment to place, such as the influence of rural upbringing , impacts their career pathway -ultimately influencing their decision to remain part of that workforce. Most studies exploring recruitment and retention focus mainly upon medicine, but extending the concept of the rural pipeline to include other professions such as nursing has the potential to strengthen understandings of rural career choice .
Rural and rurality are inherently geographical concepts but when a geographic location is imbued with meaning, it becomes place . It is not possible to separate the experience of health and health care from the place in which it is experienced, and space and place have emerged as important and central themes in nursing research .
This research needs to move beyond considering places for health care merely as geometric points, passive containers or locations of human activity , and focus conceptually on the dynamics between nursing and place, encapsulating the powerful social and cultural phenomenon permeated with power, symbolism and attachments . Place matters -as a geographical location, a lived experience, as demarcation of space, and as a site of meaning creation .
Much of the current research has focused on describing aspects of rural and remote nursing as individual entities, which does not provide insight into the complex dynamic of experiences that ultimately influences nurses' decisions to work in rural and remote settings. This perspective is important to inform recruitment strategies for students and experienced nurses in the rural and remote setting.
The aim of this study was to explore the influences on nurses' decisions to work in rural and remote healthcare settings.

Methods
A systematic review with qualitative meta-synthesis was used to answer the research question, 'What factors influence nurses' decisions to work in rural and remote healthcare settings?' The study is reported following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines .

Study inclusion
The publications had to meet the following inclusion criteria: (1) published in the English language; (2) any aspect of experiences of rural or remote nursing; (3) qualitative research. Qualitative studies were targeted as this paradigm is more appropriate to capture the experiences of rural and remote nurses. Inclusion criteria were used to screen the title and abstracts. Full text articles were first scrutinised by SCM to confirm inclusion or exclusion. All screening was conducted by a second independent reviewer, AS, RGK or MB.
Consensus was reached where debate existed around retaining or excluding an article.

Data extraction
Data were extracted by SCM, and checked by AS, RGK and MB, for the following characteristics for each retained article: author(s) and year of publication, country, focus/aim, design, method/sample, definition of 'rural'/'remote' and study limitations.

Quality appraisal
Retained articles were assessed using the CASP (Critical Appraisal Skills Programme) tool for qualitative research , which was modified to include a scoring system from each of the CASP questions where 'Yes' = 1 and 'No' or 'Can't tell' = 0. The maximum score was 10 and the minimum score was 0. All articles were critically appraised and scored by SCM and then independently scored by a second reviewer (AS, RGK or MB). The tool was not utilised to exclude articles from the synthesis but rather to enhance understanding and identify methodological limitations of the primary studies.

Synthesis of findings
Thematic synthesis was selected as it relies on an inductive lineby-line coding of text from the primary studies. By staying as close as possible to the experiential accounts of nurses working in a rural or remote setting, the aim was to generate new insights into this phenomenon.
All data were coded by hand by SCM and three key steps were undertaken in the synthesis. First, the results sections of each study were extracted and inductively coded line by line. Verbatim quotations and text were entered into NVivo v12 (QSR International; http://www.qsrinternational.com). Second, the identified master themes (dimensions) and subthemes (domains) were highlighted and organised into tables, and texts with similar content and meanings were grouped together as descriptive themes. As each study was coded, the bank of emergent themes was added to and developed. The third stage went beyond the content of the original studies by identifying and examining relationships between themes to develop an overarching analytical framework. The use of line-by-line coding enabled one of the key tasks in the synthesis of qualitative research to be undertaken: the translation of concepts from one study to another. Every sentence had at least one code applied, and most were categorised using several codes. A draft summary of the findings across the studies organised by the 18 descriptive themes was written by SCM. AS, RGK and MB commented on this draft and a final version was agreed. The analysis informed the development of a model of rural and remote nursing.

Results
The results are presented in Figure 1 using a modified PRISMA 2009 flow diagram . All independent reviewers agreed on the application of inclusion criteria and 40 full text articles were included.

Quality appraisal and analysis
Initial inter-rater agreement of the application of the quality appraisal was 85.7% (343 items in agreement of 400 CASP items (ie 10 CASP questions × 40 included articles)). The lowest agreement score (15%, 6/40 articles) was for CASP item 6 ('Has the relationship between the researcher and participants been adequately considered?'). Discussion between reviewers identified differences in how this question was interpreted. Interpretation of the question was therefore discussed at a meeting of all four reviewers and agreement reached. Additional differences in assessment were resolved through discussion until agreement of 100% for all CASP items was reached (Table 3).
Most articles scored highly for quality critique (8-10). Whilst two scored lower -(5) and (6)     Although participants voiced a strong desire to help others and to save lives, they also expressed a deep concern for their own quality of life     (Australia) . Safety: Some nurses cited personal safety as being a concern . Nurses described lone working without security personnel in the evening:

Geographical isolation:
There are four of you in the whole hospital and we don't like people to know that because we are very much at risk.   variable and evolving . The small but growing literature around remote health recognises that recruitment and retention issues arise as remote populations are smaller, more isolated and more highly dispersed -often relying on visiting services (fly-in flyout) . Due to the multidisciplinary and generalist nature of practice in remote settings, policy-makers and planners are mandated to direct resources and programs such as the preparation of specially credentialed remote area nurses to address the health needs of populations in these areas . Second, policy-makers involved in developing recruitment and retention strategies should consider how the key factors that influence nurses' decision-making to work in rural and remote areas, identified here, can be incorporated into campaigns to attract and retain nurses in these areas. The review highlights some of the many advantages for nurses working in rural and remote settings that could be emphasised in recruitment approaches or marketing materials. Some describe the opportunities available for them to step up in challenging situations, make leadership decisions and have more than one role. Evidently nurses who choose to work in rural and remote settings do so because of a combination of factors, and an understanding of their experiences and decisionmaking can help devise effective recruitment and retention strategies for this workforce at a time of global nursing shortages.
Finally, the literature has only begun to explore the connections between the person/al, profession/al and place-related dimensions of rural nursing and, whilst this article goes some way to highlight and describe the complex interconnections, further work is needed to fully understand the complexity of nurses' experiences of working in rural and remote settings and examine the interplay between the factors in MacKay's 3P model. Specifically, as most articles included a snapshot of nurses' experiences at a single moment in time, there is a particular need to understand nurses' experiences over time. In this way the complexity of the decisionmaking process and implications of decisions made to work in rural and remote settings will be better understood over the course of a career.

Unanswered questions and future research
This article has identified the many factors that influence nurses' decisions to work in rural and remote areas. A model of factors that influence nurses' decision-making to work in rural and remote areas has been outlined that can be used by policy-makers to shape targeted recruitment and retention strategies and serve as a framework for future research in this field. However, in the face of global nursing shortages, which have a disproportionately negative impact on remote and rural areas, this review shows that further research examining the interplay between the personal, professional and place-related dimensions of rural nursing is required. (Auto)biographical narratives have been used by health researchers to enable participants to understand the flow of their lives through time and space, and the interrelation between the two . Using autobiographical (or life history) approaches in rural nursing research may help to uncover nurses' rationale for their career decisions in the context of the relationships with people and places in which they were made. Through narrative, life stories are appropriate for understanding a lifetime of occupational experiences and for appreciating the personal, professional, social, economic, historical and geographical influences that shape these experiences .

Strengths and limitations
This appears to be the first systematic review and thematic synthesis to explore the evidence around the dimensions and domains that influence nurses' decision-making and experiences of working in rural and remote healthcare settings. Studies were generally of a high quality, perhaps reflecting the use of qualitative reporting guidelines such as COREQ-32 (consolidated criteria for reporting qualitative research) . Notwithstanding the use of the CASP tool , quality appraisal retains a degree of subjectivity, and although all articles were critically appraised and scored by SCM and then independently scored by a second reviewer (AS, RGK or MB) it is possible that other researchers may have appraised the quality of the studies in a different way. Only English language articles were included, and thus the findings of this review may have limited relevance to countries where English is not widely spoken. Although limited, due to the inclusion of only three qualitative remote nursing articles, this review has highlighted that the dimensions and domains of rural nursing seem to be synonymous with those of remote nursing. There is a scarcity of international qualitative remote nursing research evidence to enhance understanding of nursing in more isolated and remote settings.

Conclusion
This review identifies the factors influencing nurses' decisionmaking to remain in or leave areas of remote and rural work. To date, there is a paucity of qualitative rural nursing research undertaken in the UK, a lack of explicit definitions of rural and remote nursing in many studies, and a tendency to examine factors in isolation. MacKay's 3P model highlights the multiple and complex factors at play that guide nurses' decisions to remain in or leave rural and remote settings. This three-dimensional model (person/al, profession/al and place) will aid policy-makers to tailor recruitment and retention strategies for rural and remote areas.
However, further research that examines the complex interplay of these multiple factors over time is required to inform action to enhance these strategies to address the global shortage of nurses in rural and remote settings.