Results are presented on respondent characteristics, their perceptions of life and posts in rural areas, and their perceptions of strategies to improve rural recruitment and retention, drawing from both the SAQ and FGD data.
Characteristics of respondents
Of the 462 students invited, 345 agreed to participate, giving a response rate of 92% for pre-service students and 63% for upgrading students. The lower rate amongst the latter was attributed to difficulties in communicating the invitations, long travel distances from work stations to data collection points, and students’ work commitments. Respondents were divided approximately equally between pre-service and upgrading students (48.1% and 51.9% respectively), and 34.5% were from the most urban MTC in Nairobi (Additional file 1). Two thirds described themselves as having been born in a rural or relatively rural area.
Most students were female (75.4%). The upgraders formed an older group, with a mean age of 38 years (range 24-52) compared with 24 years (range 20-40) for pre-service students. Upgraders were also more likely to be married and to have children (Table 1). Level of education of parents was higher for pre-service students than for upgraders (77.7% and 72.3% of pre-service students’ fathers and mothers, respectively, had completed primary education, compared to 57.5% and 40.2% for upgraders). For most students, parents and family members paid for their studies, with only a small proportion (9.9%) obtaining scholarships for their training, of which the majority (7%) received government scholarships. All pre-service interviewees were full-time on-campus students, while all upgrading interviewees were studying on a distance learning basis, reporting to the college for a few weeks to attend introduction to modules or to sit exams.
More upgrading trainees had chosen nursing as their first career choice (77.7%) compared to pre-service trainees (61.5%). In FGDs, some pre-service students stated that they had agreed to pursue nursing in response to parental pressure, or that nursing only became an option because they failed to get accepted into their preferred training programmes such as clinical medicine and pharmacy.
“…actually I applied for pharmacy…. but they took me for nursing and I had no choice because I had already applied three times, I was not going to lose the chance” Pre-service nursing student
Experience of working in rural areas was very different between the two groups. 68.7% of upgrading trainees had already held posts in rural areas, in contrast to pre-service students who had no rural (or urban) job experience.
When asked in FGDs which sector they would target upon graduation, upgrading students did not appear to have a strong preference for any particular sector but a minority of pre-service students favored private hospitals and non-governmental organizations (NGOs) which are mainly located in urban areas. These facilities were associated with higher salaries.
“I would prefer after college to go maybe to private sector because there (for) one, I’m assured of a good salary…” Pre-service nursing student
Perceptions of rural areas
A preliminary PCA was conducted of statements numbered 1-12 in Additional File 2, which indicated that they could be broadly grouped into two domains. The first group of variables included statements 1-4 (Cronbach’s alpha of 0.66) which all described life in rural areas. The second construct pooled together statements 5-11 (Cronbach’s alpha of 0.51) which pertained to work in rural areas. One statement (number 12) did not fit within either domain.
Life in rural areas
Students’ responses in FGDs suggested they generally understood rural areas to be those which are fairly remote with poor infrastructure (bad roads, limited transport services, no electricity, poor mobile phone network, and low water supply), poor health services, limited variety of available housing and hardly any recreational facilities.
“…you know our country how it is, infrastructure is bad, if you take me to a remote area, there is no accessibility, there is no infrastructure, there are no telephones, and there are no roads, it rains…I stay there for months without talking to my people in the urban…” Upgrading nursing student
Comparatively, urban areas were perceived to be more accessible with stronger infrastructure, better health services and educational institutions, and a variety of recreational facilities. Upgrading students, who were mostly married, commented that they often get separated from their children when they took rural posts, as their children were schooled away from them in urban areas as rural schools were considered to be of substandard quality.
However, during FGDs, rural areas were more positively often associated with a lower cost of living, with lower housing rents, school fees, and food prices reported.
“…the nurses who are out there, me I don’t hear them complain, they can afford. They eat food from the shambas (farms); things are not as expensive…” Pre-service nursing student
“Like in Nairobi to get a one bed-roomed house you need around KES 8000 (USD 102.5) but like where I went for my district experience, you could get a house for KES 1500 (USD 19.2) per month” Pre-service nursing student
When asked whether they were willing to work in any rural area in the country, both groups of students expressed fear of working in communities dominated by other tribes. They attributed their fear to post election violence that cut across the country in late 2007 and early 2008, mainly affecting rural areas.
“…I was on my marks just in case something happens I run away, and in fact one of the facilities that I personally initiated, I never went there for a long time because of fear of the post election violence, so but once you know that there is that security you feel good” Upgrading nursing student
Students cited examples of colleagues and family members who were forcefully evicted from their homes or working areas because of ethnic differences.
“Like myself if am told I go to Mount Elgon that place called Ekopsiro, I would not go for one there are two colleagues whose lives went, so you could not admire going to that particular place” Upgrading nursing student
Likert scale responses contrasting life in rural and urban areas did not elicit strong views from pre-service or upgrading students (Table 2), though respondents gave some indication that they found rural housing and lifestyles unappealing. The PCA conducted for this construct (based on statements 1, 2, 3 & 4), produced a first principal component that accounted for 50.3% of the total variance, which was used to produce a score reporting individuals’ perceptions of life in rural areas (a higher PCA score indicated stronger preference for rural areas) (Additional file 3). We modeled the determinants of this index using multivariable regression with the following independent variables: trainee type (upgrading or pre-service), age, sex, marital status, having children, being born in a rural area, and location of MTC (Additional file 4). The only significant finding was that students attending Kakamega MTC had generally more positive perceptions of “life in rural areas”.
Nursing posts in rural areas
Likert scale responses indicated that nursing students (both pre-service and upgraders) had mixed perceptions of nursing posts in rural areas. On the one hand they associated them with lower incomes, slow career advancement and workplace stress, but on the other hand they did not feel that they would be frightened to work there, that it would be difficult to bring up children or that they would be without support from colleagues and supervisors (Table 2). PCA on the 7 variables in this domain (statements 5-11 in Table 2) produced a first component which accounted for 26% of the total variance (Table 3). From the regression, being an upgrading student had a significantly negative effect on preferences for working in rural areas, but being older had a positive effect (Table 4).
During discussions upgrading students shared the view that poor communication channels in rural areas limited the flow of information on training opportunities such as workshops and seminars. In addition, they revealed that staff shortages denied them the opportunity to pursue their studies because a replacement was not always available.
“…when you stay in rural community as a health worker, you might end up missing some of the privileges that people in town do enjoy like maybe there are some seminars and you are not aware…like someone working here at PGH [Provincial General Hospital] you may be coming to further your studies here at MTC unlike when you are in rural area, you just stagnate there, there is no advancement” Pre-service nursing student
When discussing provision of allowances for nursing posts, participants acknowledged the fact that rural posts attract lower housing allowances compared to those offered in urban posts. Upgrading students were however quick to point out that the higher allowances paid in urban posts were used to cater for higher living expenses in these areas.
Upgrading students held the view that positions in rural dispensaries or health centers allowed for more autonomy at work, reflecting the low number of staff per facility, and better coordination of activities. They alluded to the fact that division of work and assignment of duties is much easier with fewer staff.
“The work is there but, because in the rural we have three people, we know now it is the end of the month, we know we have ten reports to be written …. We know it is our responsibility so we know how to do division of work” Upgrading nursing student
However, some pre-service students held more negative opinions of working in rural facilities, stating that unfavorable work conditions, such as higher workloads, poor staffing, infrequent support supervision and inadequate equipment and supplies, would make it difficult to perform daily duties or limit them to managing minor cases.
“You know when you are working in the rural areas, it’s like you are just working with the community, and you don’t grow. You just deal with the most common ailments….of course in the rural area you’ll never enter in a theatre like in the urban area” Pre-service nursing student
Others pointed out that some rural communities reject health workers and health care in general and prefer traditional medicine adding that such rural posts were not attractive to them.
“The real rural area is Nyadhuna... the patients have a poor attitude toward the nurses, and they prefer the TBAs [Traditional birth attendants]” Pre-service nursing student
“I think even before they post you, they should consider the community where they are taking you, because if I am taken to a community where I know I will be rejected, I cannot accept that one” Pre-service nursing student
Faith-based organizations (FBOs) which contribute approximately 40% of national healthcare mainly in rural and underserved areas were thought to pay the lowest salaries. This particular sentiment was shared amongst upgrading students who also felt that workloads in FBOs were often too high.
“when you go to some of the private hospitals especially the mission hospitals, I tell you that place is horrible because you see somebody with an experience of ten years in the same institution and cannot even afford a salary of KES 14,000 (USD 179.48) so what I mean is especially the mission hospitals, some of the mission hospitals the pay is very poor and the work load is too much…” Upgrading nursing student
Despite individual preferences both groups of trainees were of the opinion that all cadres of nurses (including ECNs and RNs) are adequately trained to work in any health facility, and that they should therefore be ready to work in lower level facilities in rural areas.
“what I think, like now there should be a channel of everybody having an opportunity to pass through the rural and the hospital because we are trained for all this” Upgrading nursing student
Strategies to recruit and retain nurses in rural areas
Varied perceptions of strategies to recruit and retain nurses were reported in the SAQ (Table 2). Students generally felt compulsory rural service for government supported students was reasonable and that, for pre-service students, the greater responsibility in a rural area might be motivating. These positive work attributes could be enhanced by better housing and prospects for career advancement. Being able to choose the rural area to work in was also felt to be of some value while there was strong support for greater rural financial incentives as a means to attract people to such posts, with the majority of students suggesting that this should be up to 50% of basic salary. Pre-service students were significantly more likely than in-service students to agree with the statements on the motivating impact of greater responsibility and the importance of decent housing.
During FGDs, nursing students in both groups were mostly unaware of any interventions introduced in Kenya to recruit and retain health workers in rural areas. Some upgrading students were aware that rural hardship allowances ranging from KES 600 (USD 7.7) to KES 1300 (USD 16.6) per month are currently offered as a means to retain some cadres in remote areas, though they were felt to be insufficient to influence decisions on whether to work in the more remote provinces.
“… in government … sometimes you are in a … place … so remote, and you don’t get risk allowance … those who get hardship allowance get a maximum of KES 1300 (US$16.6) and something, that KES 1000 (USD 12.8) can it allow me to work in North Eastern? No.” Upgrading nursing student
Students also felt that if advertisements for public sector nursing jobs specified job location and facility type, potential applicants would be able to make more informed decisions when applying for posts. Students reported that such details are not provided for standard government posts, but have been included in advertisements for the recent short-term government contracts. Recruitment procedures for the private sector and FBOs were reported to be clearer than in the public sector, allowing potential applicants to know what role they are applying for and where they will be posted.
“Most of the NGOs’ adverts are more elaborate because they have job descriptions, qualifications and all that. And you realize that hospitals [Public] give you very little information about the job you intend to apply for, maybe they just say a KRHN nurse with a diploma and a working experience of this [number of] years but I find NGOs and CBOs (community-based organizations) more elaborate on what they want when they advertise their jobs.” Pre-service nursing student
In FGDs upgrading students supported the view that rural postings in health centers and dispensaries offered nurses a valuable opportunity to carry out managerial duties as in-charges (managers) of the facilities.
“… in the villages you will be performing your managerial functions, you will manage yourself, the drugs…” Upgrading nursing student
It was suggested that rural recruitment could be boosted by recruiting MTC students from rural areas, and perhaps training them in MTCs located in relatively remote areas. Many students favored the idea, and one upgrader argued that rural MTCs should implement a ‘quota system’ and restrict three quarters of their students to be recruited locally. However, others thought this strategy would be unlikely to have a major impact on rural recruitment in the face of persistent infrastructural problems. Moreover, high illiteracy levels in some marginalized communities where very few people attain the qualifications necessary for college education were cited as a major challenge meaning that the most marginalized would be unlikely to benefit fully.
Although likert scale responses indicated that students felt support from colleagues and supervisors was adequate in rural areas, during FGDs students argued that supervision was often focused on fault-finding, and that more supportive regular supervision would encourage nurses to practice in rural areas since they would feel less neglected.
“…I have been working in a rural set up where they do not come, but the moment they will hear that facility has a problem, they will come every month hunting you, stopping your salary, yeah…that is their idea. They do not give you support…supportive supervision” Upgrading nursing student
In the SAQ, about half the upgrading and pre-service students (49.4% and 52.5% respectively) felt that “a safe job with no risk of closing down or unemployment” was the most important factor when looking for a job, ranking this more highly than “a good income so that you do not have any worries about money”, “doing an important job that gives you a feeling of accomplishment”, or “working with people you like”. This was reflected during FGDs, where the new short-term contracts for specific rural posts were generally unpopular, with permanent public contracts preferred by both pre-service and upgrading trainees. Those disliking short contracts feared the lack of pension plan and long-term job security.
“Short term contracts, you can get a lot of money at a go but going to get another job is difficult, that money you may stay with it at home and spend it completely, what will you do?” Upgrading nursing student
In addition, delayed salary payments experienced by short-term hires came out as an issue of contention.
“…they just pay for one month then they carry forward the rest of the months, you see when a person is permanently employed at the end of each month at least…[they get their salary]” Upgrading nursing student