Table 2.

Summary of Reviewed Articles

Author (year)	Study design	Analysis method	Purpose of study	Sample and setting	Measure of recruitment and/or retention	Key findings associated with recruitment and/or retention
Andrus & Fenley (1976)	Program Report/Evaluation	Descriptive statistics	Describe and evaluate a rural NP training program	10 NP graduates from rural California counties at UC Davis NP training program, evaluated years 1970–1976	Practice in rural area	NP training program that focused on recruiting rural students and preceptors, training with underserved populations, and decentralized clinicals (moving training sites away from urban/metropolitan areas to more rural areas) had success in keeping NPs working in their rural communities All (10/10) rural NP graduates from the program worked in the same rural communities they have previously lived and worked in for several years
Aysola et al. (2015)	Cross-sectional	Multivariable analysis	Evaluate the effectiveness of 1) health professional training program, 2) area health education center program, and 3) career ladder program on provider recruitment and retention	391 CHCs (employing NPs) in the United States	Practice-reported difficulty in primary care provider recruitment and retention	CHCs with career ladder programs reported less difficulty with provider recruitment compared to CHCs without career ladder program CHCs with career ladder programs reported less difficulty retaining providers compared to those without programs
Bailey (1997)	Mixed Methods	Quant: Multivariable analysis Qual: Inductive analysis	Assess the characteristics of communities that maintain access to care and the characteristics of NPs and PAs that practice in these communities	500 community residents, 11 NPs and 19 Pas from frontier communities in Colorado, Montana, North Dakota, South Dakota, Utah, and Wyoming	NP/PAs practiced for three or more years in a frontier community vs left before three years	Communities with good leadership and higher per capita income are more likely to be successful in retaining NPs and PAs
Daniels et al. (2007)	Longitudinal cohort	Multivariable analysis	Examine factors associated with recruitment and retention of health care professional graduates	765 health professional program graduates from University of New Mexico (incl. MDs, NPs, PAs,)	Whether participant’ s first employment is rural or moved to rural if previously urban, and whether rural participant stayed rural	Factors important in choosing rural practice included clinician’s desire to serve community, rural background, participation in rural training, loan forgiveness/financial aid obligation, preference for smaller community size, and return to hometown Factors important in staying rural include community size and return to hometown
Doyle et al. (2017)	Retrospective cohort	Descriptive statistics	Assess the effectiveness of the Advanced Nursing Education Expansion (ANEE) program.	26 ANEE program grantees and 172 NP graduates	Practice location after graduation	ANEE program was created to increase number of NPs in primary care, 40.8% of training sites were in underserved areas 15.1% of ANEE graduates work in rural communities; 44.8% work in areas with HPSA designation
Edwards et al. (2006)	Cross-sectional	Descriptive statistics	Examine the effect of East Tennessee State University’s Title VII & VIII programs to promote interest in rural/underserved practices	371 family medicine and 342 NP program graduates from East Tennessee State University	Practice location of graduates	Title VII and VIII helped to create educational programs that increase clinical experiences in rural and other underserved communities 80% of NP graduates from this program work in HPSA or other underserved areas; 38% of NP graduates work in rural areas
Flinter (2011)	Program Report/Evaluation	Descriptive statistics	Describe and evaluate an NP residency program in a FQHC	16 NP residents at an FQHC in Connecticut	Practice in FQHC after graduation	CHC Inc’s NP residency program included precepted clinics, specialty rotation, quality improvement, and didactic sessions to improved transition to practice in FQHCs. NP residents train under a CHC NP or physician. 15/16 NP residents practiced in a FQHC after graduation
Fowkes et al. (1994)	Mixed methods	Quant: Descriptive statistics and bivariate analysis Qual: No information provided	Describe and evaluate the effectiveness of training programs in preparing graduates for practice in underserved areas	51 NP, PA, and nurse midwife training programs in the US that prepare graduates for practice in underserved areas (43 PA, NP, and CNM graduates interviewed)	Quant: Program success defined as >60% of graduates in primary care and >25% in HPSA practices; towns with <10,000 population, or >60% serving in other underserved areas. Qual: Decision to practice in underserved area	Background/experience in underserved areas and minority language background were graduates’ most frequently cited motivations for working in underserved areas Programs with dedication to underserved populations, training in underserved areas, and rural-health focused curriculum were more likely to be successful (as previously defined)
Gilman (2013)	Program Report/Evaluation	Descriptive statistics	Examine what draws health professionals to working in Delaware, what factors attract them to Delaware’s underserved areas, and what factors retain those who participate in obligatory health care recruitment programs	38 healthcare professionals (including MDs, NPs, PAs) in Delaware who participated in obligatory health care recruitment programs (NHSC, Delaware state loan repayment program, J1 visa)	Whether participant stays or relocates after end of obligatory service	Participants reported cost of living, quality of life, crime rate, and family-oriented setting as the most important community-oriented factors in their decision to stay Participants reported competitive salary, satisfactory contract terms, availability of support staff, use of technology, relationship with patients, recognition of effort, and growth opportunities as the most important job-oriented factors in their decision to stay
Hafferty & Goldberg (1986)	Cross-sectional	Multivariable analysis	Examine how different training pathways place NPs and PAs in targeted areas	210 NP and PA students from the Primary Care Associate Program created to train primary care NPs and PAs for underserved areas in California	Working within the area that NPs or PAs resided in before entering the program	Training/preceptorship close to graduate’s home residence and employment with their preceptor increase likelihood that NP/PA graduates will practice in that area Personal variables (e.g., age, sex, marital status) did not predict retention when training was controlled for Having satellite training sites in rural/underserved areas close to graduate’s home may improve likelihood for NP/PA student to stay in underserved areas
Holland et al. (2019)	Program Report/Evaluation	Descriptive statistics	Describe and evaluate the Rural Primary Care Scholars Initiative curriculum to prepare NPs for rural practice in Alabama	47 NP program graduates from the Rural Primary Care Scholars Initiative in rural Alabama	Employment as NPs in rural Alabama	NP students who participated in the Rural Primary Care Scholars Initiative program received additional placement hours with rural providers, mentoring from faculty who are experts in rural and underserved populations, training in leadership and health policy issues, and networking with rural providers 80% of program graduates are serving in rural Alabama
Kippenbrock (2004)	Cross-sectional	Descriptive statistics	Examine factors associated with NP employment in rural areas	121 NPs in rural Arkansas	Selection of employment in rural area	37% of sample reported loan repayment as a factor in choosing rural employment
Li et al. (1995)	Qualitative, focus groups	Thematic analysis	To understand the rationale behind career choices for healthcare providers who work with underserved populations	24 providers (MDs, NPs, PAs and dentist) in Salt Lake City, Utah	Decision to work with underserved populations	Providers chose to work with underserved populations because of their moral conviction, strong sense of service; they enjoyed the challenge of holistically addressing patients’ needs under limited resources.
Lindsay (2007)	Qualitative, semi-structured interviews	Thematic analysis	Explore experience of NPs and PAs by gender and geographic area	55 NPs, PAs, and nurse anesthetists in New York and Pennsylvania	Decision to work in current location (rural vs urban)	Providers were attracted to rural areas because of the rewarding work environment and appreciation from patients; greater independence, fewer “turf issues” and broad scope of practice; and their community and family ties
Negrusa et al. (2014)	Program Report/Evaluation	Multivariable analysis	Examine NHSC clinicians’ retention in high-need areas after completion of their program, and characteristics contributing to retention	1st dataset: 8,973 NHSC participants; over 1 million non-NHSC providers 2nd dataset: 18,500 NHSC participants including MDs, NPs, PAs, social workers, dentists	Serving in the same HPSA and same county or another HPSA in a different county after completion of NHSC program	Retention in HPSA area increases with age Higher NHSC provider retention in poorer and less educated communities NSHC participant less likely to remain in same HPSA area compared to non-NHSC participants, however, when NHSC participants often relocate from one HPSA area to another HPSA area; NHSC participants have higher long-term retention after initial relocation
Pathman, Fannell et. al (2012)	Program Report/Evaluation	Multivariable analysis	Examine practice, clinician, and experience factors associated with clinicians’ intention to remain at retention program sites	996 clinicians from NHSC and other similar state-run clinician retention programs, including MDs, NPs, PAs	Anticipated intention to remain at service site for 1, 2, 3, and up to 10 years after end of service term	Some states reported higher rural vs urban anticipated retention Anticipated retention was associated with clinicians’ age (>29 years), race (non-Hispanic white), whether they have children, and whether they grew up/trained in area Clinicians who reported being motivated by working with the underserved anticipated longer retention Clinicians motivated by financial support were less likely to anticipate retention Being satisfied with the practice’s administration, salary/income, and access to specialists are associated with higher anticipated retention Clinicians who report community belonging, family safety, and spousal belonging also are more likely to report anticipated retention
Pathman, Konrad et al. (2012)	Program Report/Evaluation	Multivariable analysis	Assess short, medium, and long term retention rates and factors associated with retention for NHSC clinicians	2,731 NHSC clinicians and alumni including MDs, NPs, PAs, dentists, etc.	Remaining in NHSC practice after completion of program or leaving but working in other underserved practices	Higher retention for participants in rural vs urban settings Retention is associated with: practice in a community where participant lived/trained; fit with professional, personal, and family needs; reported motivation to work in underserved areas; busy practice settings; older age; satisfaction with administration relationship, clinician support, and working at full scope of practice
Ryan et al. (1986)	Program Report/Evaluation	Descriptive statistics	Describe and evaluate Georgia Southern College’s program to prepare NP students for rural practice	28 NP graduates from Georgia Southern College’s rural NP program	Employment in rural area	The college’s NP program that recruited students based on ties to rural community and focused on rural practice training have success in placing students in underserved practices (22/28 or 79% graduates are working in underserved rural areas)
Scarbrough et al. (2016)	Cross-sectional	Descriptive statistics and bivariate analysis	Assess NHSC clinicians’ preference for retention strategies	66 NHSC clinicians in Texas	Preference for retention strategies by NHSC clinicians	Clinicians’ ranked preference for retention strategies were: 1) competitive salary, 2) professional development, 3) knowledgeable/competent support staff, 4) professional support
Sinclair-Lian et al. (2008)	Cross-sectional	Descriptive statistics and bivariate analysis	Examine the association between membership in a PBRN and clinician employment time	95 clinicians (incl. MDs, NPs, PAs) in New Mexico	Quantitative: Mean employment time in underserved practices	Clinicians who are members of PBRN have longer employment time compared to non-members (7yrs vs 4yrs)
Spetz et al. (2017)	Cross-sectional	Descriptive statistics and bivariate analysis	Compare urban and rural primary care NPs and examine factors that may influence their supply in rural regions	13,000 NPs from the 2012 National Sample Survey of Nurse Practitioners	Plan to leave position within 1–2 years	NPs in small and isolated rural areas reported less intention to leave their position compared to NPs in urban areas Rural NPs more often reported that they bill for their own services, have their own patient panels and hospital admitting privileges, and that they practice to the fullest extent of state SOP
Sullivan et al. (1978)	Cross-sectional	Descriptive statistics and bivariate analysis	Examine the characteristic of rural NPs, their practice characteristics, motivation to practice in rural areas, and satisfaction with the NP role	525 NP graduates across the U.S.	Selection of rural practice setting	“Creative approach to healthcare delivery” and role autonomy were the top reasons why rural NPs in this sample chose to work in rural practices

Note. NP = nurse practitioner; MD = physician; PA = physician assistant; CHC = community health center; NHSC = National Health Service Corp; SOP = scope of practice; FQHC = federally qualified health center; HPSA = Health Professional Shortage Area; PBRN = practice-based research network.