Recruitment and Retention for Rural Health Facilities
Rural communities often face challenges in maintaining an adequate health workforce, making it difficult to provide needed patient care or to meet staffing requirements for their facilities. Therefore, rural healthcare facilities should be proactive and strategic about recruiting and retaining personnel.
Recruitment focuses on attracting current health professionals and students to open positions or to future positions. Retention focuses on keeping healthcare professionals employed in their healthcare facilities and communities.
Successful recruitment and retention practices can minimize the number and duration of staff vacancies, which can, in turn, save money, improve quality of care, and ensure that services are provided in the community.
This guide covers recruitment and retention issues including:
- Strategies and incentives to help communities attract healthcare providers
- Organizations and programs that support the recruitment and retention of healthcare professionals
- Statistics on vacancies in rural areas
- Information on compensation, benefits, and incentives that rural facilities might offer to potential employees
For information about financial aid, see the RHIhub topic guide on Scholarships, Loans, and Loan Repayment for Rural Health Professions.
Frequently Asked Questions
- Where can rural communities get help in recruitment and retention activities?
- What is recruiting for retention?
- Why might healthcare professionals be reluctant to practice in a rural setting? What are positive aspects of rural practice?
- How can telehealth and other technology be used to make rural practice more attractive to candidates?
- What are the impacts of staff vacancies on rural healthcare facilities and the communities they serve?
- What are options for recruiting international healthcare workers to rural communities?
- What kinds of benefits and incentives can be included to make compensation packages desirable to potential employees?
- How can I research what a competitive salary would be for a given health occupation in my region?
Where can rural communities get help in recruitment and retention activities?
As one of the largest and most comprehensive recruitment and retention resources, 3RNet (National Rural Recruitment and Retention Network) is a nonprofit network funded by the Federal Office of Rural Health Policy and member dues. 3RNet has one dedicated member in each of the 50 states and the Commonwealth of the Northern Mariana Islands. Additional members include the Indian Health Service, the Cherokee Nation, and the U.S. Department of Veterans Affairs. According to Executive Director Mike Shimmens, more than 2,000 medical professional placements are achieved annually through 3RNet’s recruitment tools, with 90% of these in designated shortage areas.
Some of the services 3RNet offers include:
- A website, 3RNet.org, where health professionals seeking jobs in rural or underserved areas can register for free to browse and search jobs, and healthcare employers can post jobs through their 3RNet member
- A blog about recruitment and retention in rural and underserved areas
- The 3RNet Recruiting for Retention Academy and the 3RNet Annual Conference
- Community Based Training – 3RNet provides practical training around rural and underserved recruitment and retention. The focus is on providing tangible take-aways to improve recruiting toward retaining efforts.
- Education on recruitment and retention best practices
The main focus of 3RNet’s efforts is to connect health care professionals seeking jobs in rural or underserved communities with health care employers known as “safety net providers.” These include:
- Critical Access Hospitals
- Rural Health Clinics
- Rural hospitals
- Federally Qualified Health Centers/Community health centers
- Public health agencies
- Free clinics
- State prisons
- Community mental health centers
- Substance use disorder treatment facilities
3RNet's Annual Report, 2018-2019 includes their placement statistics and describes major accomplishments by staff and member organizations. 3RNet also publishes An Employer's Guide to Workforce Programs, which provides a general overview for employers of three programs important to the health care workforce in rural and underserved areas: Health Professional Shortage Areas (HPSAs), loan repayment programs, and the Conrad 30 J-1 Visa Waiver program.
To find the 3RNet member for your state, visit 3RNet Member Locations.
What is recruiting for retention?
Recruitment and retention are closely linked. Recruiting healthcare professionals and acclimating them to a community and facility can be expensive, and often lengthy, endeavors. It is important to recruit professionals who are well-suited to both the community and facility in which they will work, and to be proactive in retaining those professionals. This is called recruiting for retention.
According to 3RNet, recruiting for retention involves having strategies in place, thinking long-term, and making planning an ongoing process. Strategies should focus on keeping rural healthcare professionals employed in their healthcare facilities and communities as long as it remains a good fit for both parties, thus minimizing turnover. Communities that have made planning and preparation important parts of their recruitment and retention strategies have an advantage in filling vacancies if professionals leave on short notice. These steps are sometimes neglected.
Recruitment efforts should emphasize making an appropriate match for candidates, their families, healthcare facilities, and the community. Factors that contribute to a good fit include:
- Mission/purpose of the facility aligned to provider's purpose
- Region of the country desired
- Size of town/community desired
- Amenities that match family interests, such as outdoor recreation, arts/culture
- School availability and quality, if there are or will be school age children
The Community Apgar Program, developed by collaborative partners in Idaho, is a tool for improving rural communities’ recruitment and retention of family practice physicians, nurses, and hospital administrators in Critical Access Hospitals, community health centers, and Rural Health Clinics. It identifies and weighs factors important to each community regarding physician recruitment and retention and assists with specific strategic planning and improvements.
Before recruitment efforts begin, such as placing an ad in a national journal or working with a recruiter, attention should be given to planning and preparation. This includes:
- Assessing the community’s need for a primary care provider, such as a physician, physician assistant, or nurse practitioner
- Securing the support of the community. This may include school principals, bankers, and other community members who can help promote their organization and the community to potential candidates.
- Forming a recruitment and retention committee
- Budgeting for retention, something that is often not done but is extremely important
- Interviewing the candidate and meeting his or her spouse, if any, to determine how closely they match the community and the culture
- Preparing for the site visit
- Evaluating whether the current environment makes staff feel valued and identifying areas for improvement
The white paper Rural Physician Recruitment: Results from our Rural Physician and Administration Survey notes that administrators who recruit physicians with the intention of having them stay in place long term will need to “do more homework” in terms of understanding the physician's background, and should be creative when creating an offer. According to a survey referenced in this paper, the two most compelling incentives for physicians to remain in one position for five or more years are increased compensation for clinical or leadership duties and reduced hours or a more flexible work schedule.
Why might healthcare professionals be reluctant to practice in a rural setting? What are positive aspects of rural practice?
Healthcare professionals who are considering a job opportunity in a rural community may have a range of concerns such as:
- A heavy workload, with a large number of patients to see and patients who require more care
- Difficulty taking time off
- Call frequency
- Few opportunities for continuing education
- Professional isolation
- Challenges in maintaining professional boundaries
A healthcare professional's family may also bring concerns to the table when considering a rural job offer. Family concerns may include:
- Limited job opportunities for spouses
- Travel distances to attend school
- Availability of afterschool programs and daycare
Rural healthcare facilities and communities can help job seekers consider some of the rewards that balance out the challenges of a rural position. Positive aspects of rural practice can include:
- Rural practitioners can experience a greater sense of mission and accomplishment because they serve in an area of need.
- They may also find they can develop stronger relationships with patients whom they come to know in many other contexts in the community.
- There are also personal rewards for both providers and their families: a lifestyle that has a slower pace, greater access to the outdoors, and other factors that make rural life an appealing choice.
- A greater sense of practice autonomy
- Opportunities for leadership or preceptorship
- Opportunities for incentive programs such as loan repayment programs
The 2011 Journal of Rural Health article “If Only Someone Had Told Me…”: Lessons From Rural Providers discusses the challenges and rewards of rural practice as identified by rural healthcare providers.
How can telehealth and other technology be used to make rural practice more attractive to candidates?
Using technology to lessen isolation and provide support to the rural health workforce can make working in a rural setting more attractive. For example, South Dakota's Avera Health eCARE Emergency service uses two-way video equipment in rural emergency rooms to communicate with and get support from emergency-trained physicians and specialists at a central hub, 24/7. In Alaska, an eICU system allows rural providers to collaborate with Anchorage intensive care unit staff, who assist in monitoring and treating patients. Project ECHO — Extension for Community Healthcare Outcomes — allows remote primary care providers to work with academic specialists, who provide support and share knowledge about chronic disease management. For more examples, see RHIhub’s Telehealth Use in Rural Healthcare guide.
Younger providers whose training and experience include use of electronic health records and other technologies may be attracted to positions in locations where those tools are already in place. For more information on electronic health records, see RHIhub’s Health Information Technology in Rural Healthcare guide.
What are the impacts of staff vacancies on rural healthcare facilities and the communities they serve?
Quality of care is harder to maintain when the facility is understaffed. Staff may be working with fewer people to cover the same number of patients and/or working longer hours. In addition, using temporary staff may impact quality and coordination of care and can be expensive. In some cases, vacancies can even result in some services being suspended until the position is filled.
Impacts associated with vacancies may include:
- Limited healthcare services to residents throughout the community as well as the surrounding area
- Increased costs due to overtime pay for other staff
- Increased costs of coverage through locum tenens physicians (short-term physician staffing assignments) or other traveling personnel
- Costs of recruitment and training of new personnel
What are options for recruiting international healthcare workers to rural communities?
Many communities recruit international medical graduates to fill physician vacancies. The Conrad State 30 Program allows each state’s health department to request J-1 visa waivers for up to 30 foreign physicians per year. In addition to the J-1 visa waiver, non-immigrant H-1B visas can sometimes be used to fill employment gaps. The U.S. Citizenship and Immigration Services has issued temporary policy changes that impact foreign medical graduates during the COVID-19 Public Health Emergency.
What kinds of benefits and incentives can be included to make compensation packages desirable to potential employees?
Added benefits and incentives can help organizations recruit and retain employees. These may include:
- Insurance benefits
- Health insurance
- Dental insurance
- Vision insurance
- Life insurance
- Professional benefits
- Coverage of malpractice insurance
- Payment for licensure fees
- Payment for association dues
- Payment and time off for continuing education
- Limited call requirements
- Other benefits
- Retirement packages
- Paid time off
- Sick leave
- Leave for volunteer work
- Sabbaticals for research, education, or mission work
- Sign-on bonuses
- Retention bonuses
- Bonuses for meeting certain goals
- Staff recruitment bonuses (i.e. a current staff member helps find a new staff member)
- Other incentives (especially for rural and underserved areas)
- Low-interest home loans
- Relocation expenses
- Practice set-up costs
- Assistance with finding spousal employment
- Assistance with locating daycare
Underserved locations may qualify for loan repayment, which can be a significant incentive. According to Mike Shimmens, Executive Director of 3RNet, offering loan repayment or forgiveness is critical in recruiting primary care physicians to practice in underserved areas. Many of those reviewing online job boards and websites are especially interested in this benefit.
Shimmens expressed his concern that,
The number of primary care physicians available to serve in underserved areas is trending down while the demand is increasing. Finding physicians to practice in these areas of need is becoming incredibly more important and more difficult to do.
For further information regarding loan repayment, see the RHIhub topic guide on Scholarships, Loans, and Loan Repayment for Rural Health Professions.
How can I research what a competitive salary would be for a given health occupation in my region?
Professional, recruitment, consulting, and government organizations often survey healthcare providers or employers for compensation information. Participating in these surveys is a good way to gain access to their results. Research or educational organizations may also survey new graduates regarding starting salaries.
Recruitment and professional organizations may charge for wage data and some professional organizations limit access to compensation information to members only.
Key sources of salary information include the Occupational Employment Statistics: Wage Data by Occupation from the Bureau of Labor Statistics (BLS), which provides average salaries by occupation and industry with some breakdowns by state and metropolitan area. See the BLS article Using OES Occupation Profiles in a Job Search for additional information on how to use their wage data.
Here are some additional resources that provide national data. Some include further breakdowns:
Behavioral Health Occupations
- 2019 Behavioral Health Salary & Benefits Report (available for purchase)
- 2015 Salaries in Psychology
- 2019 AANP National NP Sample Survey: Compensation (available for purchase)
- An Analysis of the Labor Markets for Anesthesiology: Earnings (see page 24)
- 2019 AAPA Salary Report (available for purchase)
- AAFP Family Medicine Facts: Family Physician 2017 Income Before Taxes
- AAMC Survey of Resident/Fellow Stipends and Benefits Report, 2019-2020
- MGMA DataDive Provider Compensation Data (available for purchase)
- Medscape 2020 Physician Compensation Report
Last Reviewed: 9/15/2020