Decision criteria in health professionals choosing a rural practice setting : development of the Careers in Rural Health Tracking Survey ( CIRHTS )

Introduction: Rural background and training have previously been found to increase the likelihood of rural practice. However, practitioners of many health professions remain in shortage in rural and remote Australia. This study builds on previous work in that it includes medical, nursing and allied health professions, considers the role of the health professional’s family in employment decisions, and includes a broader array of factors influencing employment preference and the preferred location of practice. The survey also examines when students might work in a rural area. Method: The survey was designed after an extensive review of relevant literature and existing surveys, consultation with rural clinicians, and piloting with students. Approximately 500 students per year are anticipated to complete the survey while on placement at the Northern Rivers University Department of Rural Health, New South Wales, Australia, and will be contacted annually for at least 10 years.


Introduction
Limited access to health services remains a significant problem for people living in rural and remote areas of Australia [1][2][3][4] .This is in part due to difficulties in attracting and retaining health professionals to rural practice [5][6][7][8][9] .
Schemes devised to improve the recruitment and retention of the rural health workforce [1][2][3]5,[10][11][12][13][14] will only be successful over the long term if they address the issues that are important to health students in deciding to work in a rural or remote area, and target the students most likely to work in such areas 3 .
The current study is unique in that it includes all health disciplines, takes account of immediate and extended family factors that impact on employment preferences, and is longitudinal in design.It should enable researchers to follow student decisions about where they commence practice, when and if they practise in a rural area, and the association with factors that are a positive or negative influence on choosing to work in a rural area.It will examine factors that influence both recruitment, as students first move into the workforce and make their location choices, and retention as the new health professionals become settled in their career over time and make decisions to stay or leave their initial work location.This article takes a similar approach to that of DeWitt and her colleagues 25 , in that it describes the development and content of the survey tool.

Method
The Careers in Rural Health Tracking Survey (CIRHTS) was developed following a review of relevant literature and existing surveys, consultation with rural clinicians, and piloting a draft instrument with students undergoing rural placements.Some questions (such as questions 13, 14, 17 and 21; Appendix) were taken or modified from previously published questionnaires in order to make the survey comparable with other data sources 25,26 .
Approximately 500 students per year are anticipated to complete the survey while on rural placement at the Northern Rivers University Department of Rural Health, New South Wales, Australia.The placement experience can differ among disciplines, universities, and year of study.The CIRHTS, therefore, has the potential to examine the impact of repeated versus one-off, and early versus late exposure to rural practice, and the relationship between length of placement and rural uptake for different health professions.
Once recruited into the study, participants in each cohort will be followed for at least 10 years using an annual

Results
The CIRHTS survey (Appendix I) questions students in detail on their personal characteristics, family relationships, While previous research has often distinguished only between rural and urban locations, pilot data for the current study suggested that the distinction is not so simple.It could be expected that when students consider practising in a 'rural area', their mental model of 'rural' is not defined as 'outside a capital city', but rather includes a variety of settings, some of which they would be willing to work in and others they would not.One important distinction among types of rural areas is the distinction between coastal and inland areas.With more Australians than ever before looking to live and work on the coast 28 , it is important to know whether this preference is equally reflected by young health professionals.
Accordingly, CIRHTS identifies students for whom working near the coast is important, as well as those for whom it is not.
To ascertain the main drivers in student and partner location preferences, participants are asked to quantify on a Likert scale the extent to which certain factors would influence their decision to work in a rural area, from 'strongly discourage' to 'strongly encourage'.Space is also provided for respondents to name any factors that are not already listed.

Conclusions
The CIRHTS has the potential to collect a great deal of information on medical, nursing, and allied health students' regional preferences, and the issues they consider important when considering rural practice.By collecting this information and tracking students over time, it should be possible to identify the specific factors, and respective weights of each factor, that determine whether an individual will be motivated to choose rural practice.This knowledge may be particularly useful for government and industry when developing new schemes so that they provide the greatest incentive for rural practice.
questionnaire.Cohorts will consist of students having a rural © D Schofield, J Fuller, S Fletcher, H Birden, S Page, K Kostal, S Wagner, L Schultz, 2007.A licence to publish this material has been given to ARHEN http://www.rrh.org.au 3 placement in a given year, with students continuing to be recruited over the life of the study.Once in the workforce, in future waves of the study, participants will receive a modified version of the survey instrument, which will enable examination of changes in preferences over time, and will also gather information on their experiences as new health professionals, including both work and continuing education issues.The questionnaire was completed and final ethics approval was received from the University of Sydney Human Research Ethics Committee in 2006.
education and current employment, employment preferences and factors influencing those preferences, and rural background (Fig 1).Because the decision to move to a rural area may also involve a partner or spouse, most items have space for both student and spouse responses.Understanding the time dimension in a person's decisionmaking is crucial when developing initiatives to attract clinicians to rural practice.The CIRHTS is unique in that it asks students not only what size towns they would be willing to work in, but also when they might work there.For example, a student could indicate that they would work in a rural community within one year, a major urban centre within 5 years but never overseas.
Thus, CIRHTS asks participants to nominate exactly which regions of Australia they would work in and, in so doing, attempts to define areas of Australia in terms of general desirability for practice location, to identify the types of clinicians who are motivated to work in particular regions, and to characterise the positive and negative factors that go into a decision to practise in one area versus another.Maps based on the Australian Bureau of Statistics' Australian Standard Geographical Classification of regions 27 are provided to assist students and partners in completing this section of the survey.

©
D Schofield, J Fuller, S Fletcher, H Birden, S Page, K Kostal, S Wagner, L Schultz, 2007.A licence to publish this material has been given to ARHEN http://www.rrh.org.au7 Appendix I Careers in Rural Health Tracking Survey (CIRHTS) survey instrument © D Schofield, J Fuller, S Fletcher, H Birden, S Page, K Kostal, S Wagner, L Schultz, 2007.A licence to publish this material has been given to ARHEN http://www.rrh.org.au