We still need international applicants.

Sam Foster, Chief Nurse, Oxford University Hospitals, reflects on her experience visiting Kerala to interview overseas candidates for nursing recruitment.

Nova Scotia Needs Doctors: How Do We Attract and Keep Them?

Recruitment and retention of physicians, especially in rural communities, are severe public health policy problems in Canadian hospitals. This characterizes the situation in Nova Scotia. This study explored the Eastern Zone of the Nova Scotia Health Authority to determine ways to overcome the physician shortage. Six participants, all working in physician recruitment in Nova Scotia, were asked semi-structured, in-depth questions about the current recruitment process in their respective zones. The research participants presented many parallel perspectives on problems and solutions. It was determined that the biggest obstacles faced by recruiters are bureaucracy, a lack of clear communication channels, failure to track return on investment, a lack of community integration (including spousal employment supports) and a lack of clearly defined roles and responsibilities within the Eastern Zone. This study is timely given the salience of the subject, especially on the Canadian public agenda.

Case study of a method of development of a selection process for community health workers in sub-Saharan Africa.

BACKGROUND: Choosing who should be recruited as a community health worker (CHW) is an important task, for their future performance partly depends on their ability to learn the required knowledge and skills, and their personal attributes. Developing a fair and effective selection process for CHWs is a challenging task, and reports of attempts to do so are rare. This paper describes a five-stage process of development and initial testing of a CHW selection process in two CHW programmes, one in Malawi and one in Ghana, highlighting the lessons learned at each stage and offering recommendations to other CHW programme providers seeking to develop their own selection processes. CASE PRESENTATION: The five stages of selection process development were as follows: (1) review an existing selection process, (2) conduct a job analysis, (3) elicit stakeholder opinions, (4) co-design the selection process and (5) test the selection process. Good practice in selection process development from the human resource literature and the principles of co-design were considered throughout. Validity, reliability, fairness, acceptability and feasibility-the determinants of selection process utility-were considered as appropriate during stages 1 to 4 and used to guide the testing in stage 5. The selection methods used by each local team were a written test and a short interview. CONCLUSIONS: Working with stakeholders, including CHWs, helped to ensure the acceptability of the selection processes developed. Expectations of intensiveness-in particular the number of interviewers-needed to be managed as resources for selection are limited, and CHWs reported that any form of interview may be stressful. Testing highlighted the importance of piloting with CHWs to ensure clarity of wording of questions, interviewer training to maximise inter-rater reliability and the provision of guidance to applicants in advance of any selection events. Trade-offs between the different components of selection process utility are also likely to be required. Further refinements and evaluation of predictive validity (i.e. a sixth stage of development) would be recommended before roll-out.

"Posting policies don't change because there is peace or war": the staff deployment challenges for two large health employers during and after conflict in Northern Uganda.

BACKGROUND: Between 1986 and 2006, the Acholi region in Uganda experienced armed conflict which disrupted the health system including human resources. Deployment of health workers during and after conflict raises many challenges for managers due to issues of security and staff shortage. We explored how deployment policies and practices were adapted during the conflict and post-conflict periods with the aim of drawing lessons for future responses to similar conflicts. METHODS: A cross-sectional study with qualitative techniques for data collection to investigate deployment policy and practice during the conflict and post-conflict period (1986-2013) was used. The study was conducted in Amuru, Gulu and Kitgum districts in Northern Uganda in 2013. Two large health employers from Acholi were selected: the district local government and Lacor hospital, a private provider. Twenty-three key informants' interviews were conducted at the national and district level, and in-depth interviews with 10 district managers and 25 health workers. This study focused on recruitment, promotions, transfers and bonding to explore deployment policies and practices. RESULTS: There was no evidence of change in deployment policy due to conflict, but decentralisation from 1997 had a major effect for the local government employer. Lacor hospital had no formal deployment policy until 2001. Health managers in government and those working for Lacor hospital both implemented deployment policies pragmatically, especially because of the danger to staff in remote facilities. Lacor hospital introduced bonding agreements to recruit and staff their facilities. While managers in both organisations implemented the deployment policies as best as they could, some deployment-related decisions could lead to longer-term problems. CONCLUSION: It may not be possible or even appropriate to change deployment policy during or after conflict. However, given sufficient autonomy, local managers can adapt deployment policies appropriately to need, but they should also be supported with the necessary human resource management skills to enable them make appropriate decisions for deployment.

Hypothesis: improving literacy about health workforce will improve rural health workforce recruitment, retention and capability.

BACKGROUND: One of the key barriers to health in rural areas is health workforce. Poor understanding and communication about health workforce across all stakeholder groups (including the broad community) is very common and can negatively affect the health workforce, recruitment, experiences and outcomes. HYPOTHESIS: In this paper, we propose the concept of literacy about health workforce. We propose this as a specific, actionable extension of the existing and well accepted health literacy concept. We hypothesise that improving literacy about health workforce will improve, in particular, rural health workforce recruitment, retention and capability. IMPLICATIONS OF THE HYPOTHESIS: We propose that literacy about health workforce is important for all members of the health and broader system (e.g. local GP, mayor, workforce agency, health manager, Aboriginal health worker, carers, community health facilitators, patients, schools, local businesses, cultural and recreation groups) because we hypothesise their literacy about health workforce affects their capacity to make informed decisions and take action to manage their health workforce needs in direct synchrony with the community's health needs. We hypothesise that improving literacy about health workforce will improve the effectiveness and efficiency of attracting, recruiting, training, and retaining a high quality, capable, health workforce, and further, will support the development and acceptance of innovative solutions to health workforce crises such as new models of care. This hypothesis is action orientated, is testable and includes the consideration of methods to engage and improve literacy of those within and external to the health workforce.

For more than money: willingness of health professionals to stay in remote Senegal.

BACKGROUND: Poor distribution of already inadequate numbers of health professionals seriously constrains equitable access to health services in low- and middle-income countries. The Senegalese Government is currently developing policy to encourage health professionals to remain in areas defined as 'difficult'. Understanding health professional's preferences is crucial for this policy development. METHODS: Working with the Senegalese Government, a choice experiment (CE) was developed to elicit the job preferences of physicians and non-physicians. Attributes were defined using a novel mixed-methods approach, combining interviews and best-worst scaling (Case 1). Six attributes were categorised as 'individual (extrinsic) incentive' attributes ('type of contract', 'provision of training opportunities', 'provision of an allowance' and 'provision of accommodation') or 'functioning health system' attributes ('availability of basic equipment in health facilities' and 'provision of supportive supervision by health administrators'). Using face-to-face interviews, the CE was administered to 55 physicians (3909 observations) and 246 non-physicians (17 961 observations) randomly selected from those working in eight 'difficult' regions in Senegal. Conditional logit was used to analyse responses. This is the first CE to both explore the impact of contract type on rural retention and to estimate value of attributes in terms of willingness to stay (WTS) in current rural post. RESULTS: For both physicians and non-physicians, a permanent contract is the most important determinant of rural job retention, followed by availability of equipment and provision of training opportunities. Retention probabilities suggest that policy reform affecting only a single attribute is unlikely to encourage health professionals to remain in 'difficult' regions. The relative importance of an allowance is low; however, the level of such financial incentives requires further investigation. CONCLUSION: Contract type is a key factor impacting on retention. This has led the Senegalese Health Ministry to introduce a new rural assignment policy that recruits permanent staff from the pool of annually contracted healthcare professionals on the condition that they take up rural posts. While this is a useful policy development, further efforts to retain rural health workers, considering both personal incentives and the functioning of health systems, are necessary to ensure health worker numbers are adequate to meet the needs of rural communities.

Assessment of interventions to attract and retain health workers in rural Zambia: a discrete choice experiment.

BACKGROUND: Workforce shortages, particularly in rural areas, limit the delivery of health services in Zambia. Policymakers and researchers co-created this study to identify potential non-monetary employment incentives and assess their cost-effectiveness to attract and retain public sector health workers to the rural areas of Zambia. METHODS: The study consisted of two key phases: a discrete choice experiment (DCE), preceded by a qualitative component to inform DCE questionnaire development. Firstly, in qualitative interviews with 25 health workers and focus group discussions (FGDs) with 253 health students, participants were asked to discuss job attributes and potential incentives that would influence their job choices. Based on this exercise and in consultation with policymakers, job attributes were selected for inclusion in a discrete choice experiment (DCE) questionnaire. Secondly, this questionnaire, consisting of hypothetical job "choice sets," was presented to 474 practicing health workers and students. A conditional logit regression model was applied to the data from this DCE questionnaire to estimate preferences for various job attributes. Using administrative data, we estimated the cost of implementing potential attraction and retention strategies per health worker year worked. RESULTS: Although health workers preferred urban jobs to rural jobs (OR 1.39, 95% CI 1.11-1.75), employment incentives influenced health workers' decision to choose rural jobs. If superior housing was offered in a rural area compared to a basic housing allowance in an urban job, participants would be five times as likely to choose the rural job (OR 5.04, 95% CI 4.12-6.18). Education incentives and facility-based improvements also increased the likelihood of rural job uptake. Housing benefits were estimated to have the lowest total costs per health worker year worked, and offer high value in terms of cost per percentage point increase in rural job uptake. CONCLUSIONS: Non-monetary incentives such as housing, education, and facility improvements can be important motivators of health worker choice of location and could mitigate rural health workforce shortages. These results can provide valuable insight into the types of job attributes and incentives that are most likely to be effective in attracting and retaining health workers in rural areas.

Writing the Curriculum Vitae and Personal Statement.

Two of the most important components of the medical student's application for the National Resident Matching Program are the curriculum vitae (CV) and personal statement (PS). The aim of the CV is to give an itemized account of the applicant's accomplishments since the beginning of their undergraduate studies, with the main emphasis on their activities and performance in medical school. The PS, on the other hand, is the applicant's chance to give program directors (PDs) a sense of who they are. The purpose of the PS is to complement but not rehash the CV. It is an opportunity to convey what makes them fit for a residency in emergency medicine (EM). A well-written statement should guide the reader through the heartbreaks, triumphs, and inspirations that drive the applicant. Applicants should remember that the CV and PS are the first impression they brand. Both the CV and PS should be brief; easy to read; professional; honest; consistent; and free of clichés, spelling mistakes, and grammatical errors.

Using recruitment and selection to build a primary care workforce for the future.

Recruitment and selection are critical components of human resource management. They influence both the quantity and quality of the healthcare workforce. In this article, we use two different examples of primary care workers, General Practitioners in the UK and Community Health Workers in low- and middle- income countries, to illustrate how recruitment and selection are, and could be, used to enhance the primary care workforce in each setting. Both recruitment and selection can be costly, so when funding is limited, decisions on how to spend the human resources budget must be made. It could be argued that human resource management should focus on recruitment in a seller's market (an insufficient supply of applicants) and on selection in a buyer's market (sufficient applicants but concerns about their quality). We use this article to examine recruitment and selection in each type of market and highlight the interactions between these two human resource management decisions. Recruitment and selection, we argue, must be considered in both types of market; particularly in sectors where workers' labour impacts upon population health. We note the paucity of high-quality research in recruitment and selection for primary care and the need for rigorous study designs such as randomised trials.

A strategy to boost nurse recruitment.

Sam Foster, Chief Nurse, Oxford University Hospitals, discusses recruitment issues and how the concept of NHS organisations as 'anchor institutions' that contribute to the wellbeing of the local community may help.

Advocating to Protect Our Nurses: Addressing Unethical Recruitment of Foreign-Educated Nurses.

Advocacy in the nursing sector is often about advocating for patients. However, nurses have begun to put more effort into protecting their rights as workers. Advocacy on behalf of foreign-educated nurses has been a critical component of this advocacy. While foreign-educated nurses can make our nursing workforce stronger, this can only happen if they are well-treated and well-trained. Organizations across diverse missions and perspectives have come together to promote fair treatment of foreign-educated nurses, which ultimately ensures that all nurses are working as effectively as possible and that patients receive proper care. The Alliance for Ethical International Recruitment Practices' Health Care Code for Ethical Recruitment and Employment Practices represents a bottom-up agreement on which market practices constitute ethical recruitment. From a top-down level, the World Health Organization's Code of Global Practice establishes obligations and reporting requirements for member states that commit to ensuring ethical recruitment. This combination of efforts, bolstered by strong advocacy, is gaining traction as nursing migration grows at the global level. The collaboration across diverse stakeholder groups and the combination of legal, voluntary, and global efforts to promote the rights of foreign-educated nurses provides a model to apply for advocacy in different areas.

IJEPA: Gray Area for Health Policy and International Nurse Migration.

Indonesia is recognized as a nurse exporting country, with policies that encourage nursing professionals to emigrate abroad. This includes the country's adoption of international principles attempting to protect Indonesian nurses that emigrate as well as the country's own participation in a bilateral trade and investment agreement, known as the Indonesia-Japan Economic Partnership Agreement that facilitates Indonesian nurse migration to Japan. Despite the potential trade and employment benefits from sending nurses abroad under the Indonesia-Japan Economic Partnership Agreement, Indonesia itself is suffering from a crisis in nursing capacity and ensuring adequate healthcare access for its own populations. This represents a distinct challenge for Indonesia in appropriately balancing domestic health workforce needs, employment, and training opportunities for Indonesian nurses, and the need to acknowledge the rights of nurses to freely migrate abroad. Hence, this article reviews the complex operational and ethical issues associated with Indonesian health worker migration under the Indonesia-Japan Economic Partnership Agreement. It also introduces a policy proposal to improve performance of the Indonesia-Japan Economic Partnership Agreement and better align it with international principles focused on equitable health worker migration.

Challenges of Recruitment and Retention in Rural Areas.

There have long been rural health care workforce shortages; however, the urgency to find real solutions has increased with the changing health care landscape. The evidence makes a compelling case to be intentional in the candidates we support and to align educational resources across multiple systems. Programs need to continually evolve, utilizing workforce data, best practices, and new technological advances. This leads the Office of Rural Health (ORH) to secure funding for therapists practicing in integrated settings and to expand loan repayment to general surgeons and providers creating access through telehealth. While access is ORH's core mission, North Carolina's rural health plan reframed the discussion around creating healthy rural communities. This will require further refinement of the critical workforce definition, and it brings to the forefront the fact that a variety of new partnerships will be key to achieving the objective of healthy rural communities.