Introduction

It is well established that living in a rural setting in large countries including Canada, the USA and Australia presents many unique challenges compared with more urban areas.1–3 One of these challenges is the constant struggle to access the capital provided by the ‘professional’ workforce. In this case, we are defining the professional workforce as careers that typically requires postsecondary education and can include teachers, healthcare professionals, social workers and lawyers. The presence of these professions, or combinations of these professions, can play a significant role in improving rural residents’ well-being. For example, individuals who live in rural settings have an all-cause mortality rate that is higher than urban residents in Canada4 5; one explanation for this is the dearth of healthcare professionals including, doctors, nurses, physiotherapists, pharmacists and dentists in non-metropolitan areas.6 In the USA, there are shortages of doctors,7 dentists,8 teachers9 and attorneys in non-metropolitan areas.10 This is concerning, as many of these professions can have an impact on a person’s well-being. For example, the lack of attorneys can make individuals experiencing intimate partner violence more vulnerable as they might have to spend more time in dangerous situations awaiting legal counsel.10 It is imperative that the number of rural workforce professionals increases, as this could substantially impact the sustainability and the quality of life of rural people.

Researchers, policy-makers and communities in Japan, the USA, Australia and Canada have attempted different strategies to recruit and retain rural workforce professionals.11–13 To recruit health professions in particular, strategies have included financial incentives, offering unique reimbursement schemes, marketing the benefits of rural living, or hiring specialised recruiters. Overall, these strategies have seen relatively poor results, with the greatest success coming from financial incentives.11 However, financial incentives are usually more successful for recruitment purposes and less effective when retaining workforce professionals.14 One area that has shown some promise and can be optimised to prepare workforce professionals by changing their perspective on rural practice is the educational strategies used to effectively prepare postsecondary students for rural careers.15 If students are effectively prepared for the unique opportunities and have positive feelings toward rural practice, it might lead to higher levels of work satisfaction and retention.16

Educational strategies are activities that promote knowledge and skill development. These strategies can include rural placements (ie, an educational opportunity where a student has a chance to work in their field or a related field in a rural community),17 rural focused curriculums (ie, courses offered or learning objectives of a course that are focused on rural practice),18 extra development opportunities (ie, work-place opportunities that are not officially tied to a course or learning outcome)19 or other multifaceted approaches that use a combination of these different strategies.20 While perceptions of rural education strategies are not always measured, other outcomes of interest related to perceptions of rural practice include intent to practice, retention and preparation to practice in rural areas.

One of the most common educational strategies used to prepare postsecondary students for rural careers and challenge their preconceived notions on rural practice is experiential learning. Experiential learning is a learning process where students learn by doing and reflecting on the experience,21 and most professions have adopted some form of it. One example of experiential learning is in teaching education programmes where students complete a practicum where they are required to do most of the duties of a classroom teacher, that is, lesson preparation, classroom management, building relationships, and assessment and evaluation. After completing the practicum, students produce a learning artifact from reflecting on their practicum. Using experiential learning in rural communities has been recommended as an educational strategy for preparing students for working in rural areas and for workforce retention.22 A review found that students who had a rural placement increased the likelihood of rural practice by more than four times.23 Another strategy that can be used is creating specific course expectations focused on aspects of rural living and practice. In general, each institution has a certain amount of autonomy in composing their course expectations and curriculum.24 Some institutions have made strategic decisions to include topics that will specifically prepare students for rural careers.24 A scoping review on rural pharmacy curriculum and placements suggested that there was not enough evidence on universities that include a rurally focused curriculum to make any strong conclusions on their effectiveness on aiding the rural pharmacy workforce.25 In some jurisdictions, resource packages have been created to try and provide more support to preservice teachers, but the success of these programmes has yet to be completely analysed.26 Finally, some programmes use multifaceted approaches to increase the retention of rural workforce professionals. One common example is the rural pipeline, which takes a longitudinal approach. The rural pipeline attempts to support the different needs of the rural workforce professional through their education and career. Several studies suggest this approach can positively affect rural practice and retention.27 In fact, one study that examined a school partially based on the pipeline model found that students educated at that school were 2.57 times more likely to practice in rural areas.28 However, these studies are limited as some correlate educational strategies with rural retention, which fails to articulate how or why the programme is successful.

Qualitative research has provided valuable evidence on how perceptions of rural practice or rural preparedness have changed following participation in an educational strategy aimed at training students for rural practice. For instance, a study by Lopez et al on rural dental students suggested that their rural experiential learning opportunities helped correct many of the misconceptions they had about practicing in rural communities. The placement provided opportunities to show that rural dentists are busy, use cutting edge technology and the practice included more than just simple procedures. This study also found that the placement helped learners correct rural living misconceptions as they saw the diversity in rural communities and how the rural lifestyle could match their personality.29 Another study on medical students indicated that many aspects of the rural placement, specifically the clinical skills, passionate teachers and rewarding work, were important factors encouraging and preparing students for rural careers.30 Finally, one study on Australian school teachers suggested that since rural practicums were optional, students were not prepared for these experiences.31 Using qualitative evidence from studies that examine student’s perceptions of rural practice following a rural focused educational strategy might help to explain how or why a certain strategy may be effective. Synthesising the evidence from student perceptions has the potential to allow postsecondary programmes to make critical changes to their educational programmes that may improve the overall student experience and help promote rural practice, thus increasing rural retention.

Previous reviews have examined medical school programmes to increase the supply of rural physicians,32 the association between medical education and rural practice,33 and interventions for supporting nurse retention in rural areas.27 However, these reviews are limited in their narrow scope by examining a singular professional programme and superficial examination of educational strategies. Combined, these limitations have created a gap in understanding if students’ perception of rural practice changes after a rurally focused education strategy. A preliminary search of PROSPERO, the Cochrane Database of Systematic Reviews and the Joanna Briggs Institute (JBI) Evidence Synthesis was conducted, and no similar reviews were found. Understanding successful educational strategies is imperative, as they have the potential to help rural areas retain workforce professionals, and these strategies can be transferred across disciplines and countries in sustainable ways.