Understanding the Complexities of Recruitment and Retention of Allied Health Professionals in Rural Health Settings: A qualitative study

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While targeted investment exists to increase the numbers of doctors and nurses entering the rural workforce, comparatively little has been done for the professions that make up the Allied Health Scientific and Technical collective. This study aimed to explore factors that influence AHPs’ decisions to work and remain in rural settings. Methods Drawing on Interpretive Descriptive methodology, semi-structured interviews were conducted with 18 AHPs from diverse professions, ethnicities and geographical locations across Aotearoa who had experience working in rural and/or remote settings. Interviews explored participants’ career journeys, their experiences of rural practice, and factors influencing their employment decisions. Data were analysed using Reflexive Thematic Analysis. Results Three key themes were constructed: ( 1 ) Sense of Connection and Belonging, highlighting the importance of feeling connected to teams, community and place; ( 2 ) Safe and Supported Practice, emphasising appropriate resources, professional development, and leadership relationships; ( 3 ) Creating Roles People Want to Come For, encompassing recruitment experiences, variety of work, growth pathways and scope of practice. These themes were infused with a concept of ‘Fit’, a felt sense of being in the right place, personally and professionally. Conclusion This study provides insights into the perspectives of rural AHPs in Aotearoa New Zealand. Findings suggest that successful recruitment and retention requires attention to both professional and personal factors, with particular emphasis on creating environments where AHPs feel valued, supported to develop their practice, and connected to their communities. These insights can inform the development of targeted strategies to strengthen the rural AHP workforce. Allied Health Professionals rural health recruitment retention workforce Aotearoa New Zealand Figures Figure 1 Background The health workforce is stretched to its limits in Aotearoa New Zealand and internationally. Rural and remote communities, which are often the first to be impacted by workforce shortages, struggle to recruit and retain staff ( 1 – 3 ). While targeted investment in academic, political and financial strategies has aimed to increase the numbers of doctors and nurses entering the rural workforce and support them to stay, comparatively little has been done for the professions that make up the Allied Health Scientific and Technical (AHST) collective ( 4 ). Allied Health Professionals (AHPs) are clinicians, scientists, therapists and technicians who possess their own unique and specialised expertise in preventing, diagnosing and treating conditions and illnesses ( 5 ). In Aotearoa there are more than 40 professional groups included within this broad category ( 6 ), regulated by the Health Practitioners Competence Assurance Act (2003), the Social Workers Registration Act (2003) ( 8 ) or self-regulated ( 9 ). The challenges facing rural health providers in relation to the recruitment and retention of AHPs have been well documented internationally ( 10 – 12 ), but there is limited research specific to the Aotearoa New Zealand context. In the absence of research exploring factors contributing to the challenges in recruitment and retention of AHPs, organisations have invested in strategies informed by anecdotal “evidence”, individual viewpoints, or have drawn on data derived in the context of the nursing or medical workforce. Drawing on data from different professional contexts, with different training pathways, regulatory frameworks and scopes of practice presents significant challenges for developing strategies that address the unique needs and perspectives of AHPs. There is a need for research that explores the specific factors that influence AHP’s decisions to work and remain in rural settings, to inform the development of more effective, evidence-based approaches to recruitment and retention. This research aimed to explore what matters to AHPs in rural and/or remote contexts and how these insights could inform recruitment and retention practices for rural and/or remote health settings. By understanding the attractive aspects of living and working rurally for AHPs, this study sought to develop knowledge that could be applied to strengthen the rural AHP workforce in Aotearoa New Zealand, with potential application for rural health systems globally. Methods This study employed an Interpretive Descriptive methodology, a qualitative approach developed to support researchers exploring practice-oriented phenomena ( 13 ). This methodology was chosen for its pragmatic approach to examining challenges within practice settings, with an explicit focus on generating knowledge applicable to real-world clinical settings. The analysis was informed by Reflexive Thematic Analysis ( 14 ), which enabled identification of patterns of meaning within the data. Researcher Characteristics and Reflexivity The primary author (JG) was an Allied Health leader working in a rural location at the time of the research, which provided both insights and potential subjectivities. The researcher engaged in reflective practice throughout the study, examining how her disciplinary background (social work), leadership role, and rural connections influenced her engagement with participants and analysis of data. The researcher’s professional role also presented potential conflicts with some participants, which were managed through use of independent interviewers where needed. The research team also included two experienced allied health researchers who served as supervisors: NK, a psychologist and Professor with extensive qualitative and allied health research experience and lived rural experience; and PL, a physiotherapist and Associate Professor with mixed methods and allied health research expertise. Both supervisors contributed to research design, ongoing analysis discussions, and interpretation of findings, bringing complementary perspectives that enhanced the rigour of the research process. Sampling and Recruitment Participants were eligible if they were a registered AHP and self-identified as having worked in a rural or remote setting within the last five years, were currently working in such a setting, or were actively seeking to work in one. The decision to use self-identification rather than a formal geographic classification system was deliberate for several reasons. First, at the time of recruitment (2019), the now-established Geographic Classification for Health ( 15 ) had not yet been developed. Second, self-identification allowed participants to articulate their own lived experience of rurality, acknowledging that the experience of rural practice encompasses more than geographic distance alone and includes factors such as service availability, professional isolation, and community context. Third, this approach reduced potential barriers to participation by eliminating the need for participants to disclose specific workplace locations during initial recruitment. This was important for maintaining confidentiality in small rural health networks where individuals might be easily identified. A purposive sampling approach was used to ensure diversity across professions, geographical locations, ethnicities, and career stages. Potential participants were recruited through multiple channels including social media, organisational newsletters, professional networks and word of mouth. Information about the study was distributed through AHP professional bodies and rural health networks. Potential participants responded to the invitation to take part by completing a brief expression of interest via an online survey which captured key demographic information to support the sampling process. Data Collection Semi-structured interviews were conducted between July 2019 and December 2021. They were conducted via videoconferencing due to geographical dispersion and the impact of the COVID-19 pandemic, which allowed participants to engage from their preferred location. The interview guide explored participants’ career journeys, experiences of rural practice, and factors influencing their employment decisions ( 16 ). Specific topics included how participants chose their profession, what attracted them to rural practice, experiences of working in rural settings, perspectives on professional development and support, and suggestions for improving recruitment and retention. Interviews were conducted by the primary author, except where participants were known to the researcher in her professional capacity, in which case they were conducted by NK. Interviews were audio-recorded and lasted between 45–60 minutes. Data Analysis Interviews were transcribed verbatim and analysed using Reflexive Thematic Analysis ( 14 ). Analysis followed six phases: familiarisation with the data, generating initial codes, identifying themes, reviewing themes, defining and naming themes, and reporting. Initial coding was conducted manually on printed transcripts, followed by use of NVivo™ software to organise and visualise data. To enhance rigour, the primary author engaged in ongoing reflection through journaling, discussed emergent findings with the research team, and moved iteratively and recursively between individual transcripts, coding and thematic structures. Ethical Considerations Ethical approval was obtained from Auckland University of Technology Ethics Committee (AUTEC 18/424). Informed consent was gained through a two-phase process: initially via the online recruitment survey, and then verbally at the beginning of each interview. Particular attention was paid to managing potential conflicts of interest where participants were employed by the same organisation as the researcher. Anonymity and confidentiality were maintained through removal of identifying information from transcripts and secure data storage. Results Forty-five people initially expressed interest via the online recruitment survey. The final sample of 18 participants were selected to ensure diversity across key characteristics. All participants were female, ranging in age from 23 to 63 years, with most being either 20–30 years (n = 6) or over 50 years (n = 6). Participants identified as Pākehā / New Zealander (n = 11), Māori (n = 4), Samoan (n = 1), and from beyond the Pacific (n = 2). They represented seven Allied Health professions including social work (m = 7), physiotherapy (n = 4), music therapy (n = 2), occupational therapy (n = 2), psychology (n = 1), dietetics (n = 1) and pharmacy (n = 1). Participants were geographically spread throughout Aotearoa, representing areas of differing rurality and with varying proximity to urban centres. Three interconnected themes that capture what attracts and retains AHPs in rural practice were constructed through analysis. These were Sense of Connection and Belonging, Safe and Supported Practice, and Creating Roles People Want to Come For. These themes were infused with an overarching concept of Fit; a felt sense of being in the right place, professionally and personally. The themes, and their sub-themes are visually represented in Fig. 1 . Sense of Connection and Belonging The relationships AHPs form with their teams, their communities, and their environment emerged as fundamental to their experience of rural practice. Participants consistently described how these connections acted as critical determinants of their decision to remain in or leave rural roles. Connection and belonging functioned not merely as pleasant additions to workplace satisfaction, but as essential components of professional sustainability in rural contexts. The multi-dimensional nature of these connections, which spanned professional networks, personal relationships, community engagement, and environmental attachment, created an interwoven experience where work and life naturally blended. As one participant explained: "We look after each other. Everything is not sweetness and light, but when it is not it's out there in the open, it happens in the team room and not niggling behind people's backs" (P1). This theme encompassed the importance of feeling connected to teams, communities and place. This sense of connection often manifested as a deep satisfaction with one's position: "I'm thankful to be here... it's good to know you're where you're supposed to be." (P2) When these connections were absent or fractured, participants reported that even otherwise attractive roles became unsustainable, highlighting connection and belonging as key factors in retention rather than optional benefits. Three sub-themes were identified: Feeling Cared About, Personal Relationships and In Service. Feeling Cared About reflected experiences of being recognised as individuals with unique circumstances and needs. This included practical support for work-life integration and recognition of the rural context. “I can talk to them about you know, how there is no grass growth and have they had to sell off their stock, and it’s um, it’s a world I am interested in” (P1) Participants described actions that demonstrated care within teams, such as “someone bringing in a crockpot of soup on a chilly day for everyone to enjoy” (P1) or “loaning bicycles to new graduates and students” (P18) to help them experience the local environment. The micro-moments mattered the most; those acts that showed people they were valued as humans, not just as colleagues. Personal Relationships highlighted the significance of forming genuine connections within rural communities. Participants noted how communities and organisations that facilitated social connections for incoming staff were appreciated. “In [my previous rural role] I didn’t really experience that, it was a lot harder to make friends. So I definitely think the timing of when you come in, and also having, just the fact that the other people or, the only thing we had in common was that we didn’t know the town … we ended up all getting together coz we were all new to town” (P16) These relationships were perceived to provide a balance against the ‘always on’ nature of rural practice and space to maintain professional boundaries, factors that increase the likelihood of AHPs staying and thriving in rural practice settings. In Service captured participants’ commitment to contributing to their communities beyond their professional roles. For some, this was a strategic part of integration. “I made a decision, I was going to start getting involved in stuff that was here, so my life increasingly became [locally] focused rather than [back in the city] and I started doing voluntary ambulance work and I also met my husband through a flatmate I had at the time, so increasingly, suddenly my world was over here rather than in [the city]” (P17) For others, particularly Māori participants, service was connected to a sense of obligation to their home communities. “I feel like I owe people at home something and that’s quite a motivating factor. I also feel like I fit there, so um, or that I’m more useful because I understand people there” (P5) Safe and Supported Practice Safety and support for rural AHPs extends well beyond traditional risk management frameworks. Participants described multilayered concepts of safety that encompassed not only physical wellbeing but also professional practice, development and wellbeing. For rural practitioners, particularly those working as sole clinicians in geographically isolated areas these dimensions took on heightened significance. “I feel attracted to areas where, when people talk about their jobs, they enjoy the people that they’re working with and they feel safe and supported”. (P11) Participants communicated that rural practice safety was built on strong interprofessional relationships where risk could be shared through mechanisms such as multidisciplinary case reviews and quality planning. They valued environments where their competence was recognised, their learning prioritised and their geographical context understood by leaders and urban colleagues alike. The absence of these elements created not only frustration but also genuine concern about their ability to practice effectively and safely. This theme captured the elements that enabled AHPs to practice safely and effectively in rural settings. Three key sub-themes were identified: Connectivity and Technology, Valuing Learning, and Relationship with Leader(ship). Connectivity and Technology highlighted both challenges and enablers related to technology access. Participants described limitations such as “one laptop for the whole team to share” (P1) and areas without mobile coverage, creating safety concerns for lone practitioners. Systems designed and overseen from urban spaces created a sense of the rural practitioners’ needs being less important. “The infrastructure I think is poor. Provision of infrastructure and the preparation for someone walking into their job is poor compared to say, what I heard reported in [urban centre] for example.” (P17) Conversely when technology was provided, it was highly valued: “It’s actually smart and it works.” (P1) Valuing Learning focused on participants’ experiences of professional development access and support. Restrictive learning policies were experienced as barriers to professional growth. “I don’t want to go to the same entry level talk every year just to count them in my CPD [continuing professional development] folder. Like, I want it to actually be clinically significant” (P14) Many participants perceived inequities compared to medical and nursing colleagues, in terms of both funding and the career pathways professional development enabled. “The nurses take that, become geriatrician nurse specialists, pulmonary nurse specialists, rehab nurse specialists, stroke nurse specialists. [We] aren’t sought for those roles at all” (P7) Relationship with Leader(ship) were particularly significant for remote practice. Trusting relationships with managers enabled independent practice while providing necessary support. “I feel like I’ve got that freedom. She does, she definitely trusts me that I’ll do the work” (P16) Leaders who personally experienced the rural context, and demonstrated their understanding of rural realities were highly valued. “Within 45 minutes of being here, she had two assessments to do in [a neighbouring town] and we needed a third one to do here in [town]. And she was just like, ‘So what do you guys normally do when you have got this?’” (P1) Creating Roles People Want to Come For In the competitive landscape of health workforce recruitment across Aotearoa, participants highlighted that rural roles needed to offer more than financial incentives to be considered worthwhile. They described a complex interplay of factors that collectively made a position ‘worth it’ in terms of personal and professional satisfaction. “You have to work for love rather than money … if you really enjoy the work then you do end up taking the role”. (P4) For many participants, the intrinsic rewards of rural practice provided motivation beyond remuneration. "I want to stay rural because of all the unique things that makes rural practice what it is." (P6) Participants articulated that a fulfilling role needed to offer professional growth, intellectual stimulation, autonomy and alignment with personal circumstances, all elements that often presented uniquely in rural contexts. This theme encompasses the characteristics that made rural roles attractive. Six sub-themes were identified: Recruitment Experiences, Variety of Work, Growth Pathways, Freedom and Scope, Lifespan of Roles, and The Right Role. Recruitment Experiences highlighted how first impressions shaped decisions to take rural roles. Participants reported mixed experiences, from slow processes contradicting messages of urgency to thoughtful approaches like offering employment support for partner. “Talking to people about their partners who are moving with them, and what they do and giving them connections”. (P3) Variety of Work was consistently identified as a significant attraction of rural practice. “I like the variety, so that keeps my head engaged. It means I know a little about a lot, instead of a lot about a little” (P6) Working across age groups and conditions provided stimulation and professional development. “I also like that … you know you see a baby and a 100-year old in the same day. So I like the variety and the challenge” (P6) Growth Pathways addressed the importance of visible opportunities for professional development and advancement. “If you could do more by being here, so it’s a more interesting job on the ground, but as part of that you were supported to maybe get a couple of papers towards a post-grad diploma or you ended up with a post-grad certificate that you could then use towards something else” (P17) Participants contrasted this with the frustrating experiences where advancement seemed impossible, or invisible. “If I wanted to progress in terms of my career I would need to leave [this town], definitely” (P10) Freedom and Scope referred to the autonomy and breadth of practice available in rural settings. This freedom and broad scope was both challenging and deeply rewarding for rural AHPs. “I get to work with them in such a diverse way” (P8) Participants valued being able to work at the edges of their scope, though they noted their skills were not always recognised by urban counterparts, regulators or professional associations. Lifespan of Roles acknowledged that roles have natural cycles. This influenced expectations about tenure, such as recognising the seasonal flexibility required when AHPs also held farming responsibilities, or for new graduates. “I think at the age and stage they’re at it’s just that next progression in their careers, they just want to go and do something a bit different somewhere else. That seems to be the norm”. (P17) The Right Role captured the importance of alignment between personal circumstances, values and job requirements. “I was attracted back and to the rural areas coz they could offer me what fitted with my family life, and my husband’s occupation” (P15) Fit: An Overarching Concept Weaving through all three theses was the concept of Fit, a felt sense of being in the right place at the right time. This encompassed alignment with personal values, connection to community, sustainability of the role to career stage and goals, and compatibility with lifestyle preferences. "It's a dream job for … someone like me." (P2) While being born rurally or trained rurally does increase the likelihood of a sense of fit, the participants who fit this profile, and those that did not agreed that the benefits of finding professional, cultural and environmental fit could be achieved without a rural background. This sense of Fit appeared to outweigh specific challenges that participants face, and when Fit was absent it often triggered their decision to leave the rural role. “I said to her the other day, ‘would you come back to the hospital?’ And she was like, ‘way too white (laugh)’ so and she was just absolutely up front, like, ‘No, there’s no fit for me there’” (P18) Participants noted that Fit can be developed and nurtured through supportive leadership, clear and transparent growth pathways, strong professional networks and opportunities to integrate into their communities; components of which can be found across the themes presented above. Discussion This study provides new insights into the experiences and perspectives of AHPs working in rural and remote settings in Aotearoa. The findings align with international literature in some respects while offering unique contributions specific to the Aotearoa context. The importance of Connect and Belonging resonates with research by Cosgrave ( 10 ) and Kumar, Tian ( 11 ), who similarly found that supportive professional relationships and community integration significantly influence retention. However, our findings particularly highlight the reciprocal nature of these relationships. AHPs both receive and provide care within their communities, and the importance of service as an expression of connection was especially significant for Māori participants. The concept of Safe and Supported Practice extends existing literature on professional development access ( 17 , 18 ) by emphasising perceived inequities between AHPs and other professions. This perceived hierarchical valuing of workforce groups appears to be a significant factor in AHPs’ experiences of feeling undervalued, consistent with findings from Walker, Blattner ( 19 ). A significant contributing factor to these experiences was what Fors ( 20 ) terms geographical narcissism - the tendency for urban-based professionals and systems to devalue rural health and expertise. This manifested in how decisions were made without understanding rural contexts, how professional development was structured, and how rural AHPs felt their skills were perceived by urban counterparts, further compounding their sense of being undervalued within health system hierarchies. Our findings around Creating Roles People Want to Come For challenge some common assumptions about rural recruitment. Contrary to literature emphasising financial incentives ( 21 ) or lifestyle factors such as outdoor activities ( 22 ), our participants placed greater emphasis on professional aspects such as scope of practice, variety and growth opportunities. This suggests that professional satisfaction may be a more powerful motivator than previously recognised. The overarching concept of Fit offers a novel contribution to understanding rural AHP workforce issues. While previous research has examined various aspects of ‘fit’ ( 23 , 24 ), our study suggests a more holistic conceptualisation that integrates professional, personal and place-based elements. This aligns with recent research on place attachment and belonging-in-place ( 25 ), and extends these concepts by emphasising how fit operates simultaneously across multiple dimensions. Our findings suggest that Fit is not merely a static attribute but a dynamic and relational construct that can be cultivated over time. Participants described how their sense of Fit evolved through meaningful engagement with communities, development of professional confidence, and acquisition of context-specific knowledge. This challenges simplistic recruitment models that rely primarily on rural origin or training as predictors of rural retention ( 26 , 27 ). Instead, it suggests that creating conditions where AHPs can develop and experience Fit across multiple dimensions may be more effective. Furthermore, Fit appears to function as both a protective factor during challenges and a threshold concept for retention decisions ( 28 ). When Fit was strong, participants described weathering significant workplace challenges; when it deteriorated, departure became inevitable. This conceptualisation offers a useful framework for understanding the complex interplay of factors that influence AHPs’ decisions to remain in or leave rural settings and could inform more nuanced approaches to workforce planning. Strengths and Limitations This study has several strengths and limitations. Strengths include the diversity of professions, geographical locations, and cultural backgrounds represented. This study is also the first of its kind in Aotearoa, providing valuable context-specific insights previously absent from the literature. The Interpretive Descriptive methodology ( 13 ) enabled robust analysis while maintaining focus on practice applications. Limitations include that all participants identified as female, limiting insights into potential gender differences. Additionally, self-identification of rural practice rather than using geographic classification such as Whitehead, Davie ( 15 )’s Geographical Classification for Health may have affected sample composition. Implications for Practice The findings have several implications for rural health organisations, line managers, recruiters, professional bodies and educators. Successful recruitment and retention strategies should address all three thematic areas identified: fostering connection and belonging, ensuring safe and supported practice, and creating attractive roles. Practically, this means developing recruitment processes that reflect organisational values, facilitating social and professional networks for new staff, ensuring appropriate resources and technology, providing equitable access to professional development and creating visible growth pathways. Additionally, organisations should examine how they value and promote AHP contributions, challenging hierarchical structures that privilege medical and nursing perspectives ( 29 ). Conclusion This study provides significant insights into the experiences and perspectives of AHPs working in rural and remote settings in Aotearoa New Zealand. The findings highlight that successful recruitment and retention requires attention to both professional and personal factors, with particular emphasis on creating environments where AHPs feel valued, supported to develop their practice and connected to their communities. The overarching concept of Fit offers a useful framework for understanding how various elements interact to influence AHPs’ decisions to work and remain in rural settings. This supports a shift from relying on stereotypical rural attractions or financial incentives towards creating meaningful roles and supportive environments that enable AHPs to contribute their full potential. Rather than viewing the rural AHP workforce challenge as primarily one of recruitment, this research suggests that creating conditions where AHPs experience fit across multiple dimensions will naturally enhance both recruitment and retention. Further research could explore how these findings might be implemented and evaluated in practice settings and further examine the concept of Fit as it relates to rural health workforce development. Abbreviations AHPs Allied Health Professionals COVID-19 Coronavirus Disease of 2019 CPD Continuing Professional Development Declarations Acknowledgements We are grateful to the 18 AHPs who gave up their time to participate in the research. Author Contributions JG designed the study with support from PL and NK; JG and NK were involved in the data collection; JG analysed and interpreted the data with support from NK and PL; JG drafted the manuscript with support from NK and PL. All authors approved the submitted version. Data Availability The qualitative datasets generated during this study are not publicly available due to their co-constructed nature between researcher and participants, the sensitive personal narratives contained within, and ethical constraints. Participants consented to share their experiences with the assurance that raw data would remain confidential to the research team. The contextual and potentially identifiable nature of in-depth qualitative data makes complete de-identification challenging whilst preserving data integrity. Ethics approval and consent to participate While the Declaration of Helsinki primarily addresses medical research conducted by physicians and is therefore not directly relevant to this qualitative study; exploring allied health professional perspectives, it has adhered to the core ethical principles regarding human subjects research, including informed consent, voluntary participation, confidentiality, and minimisation of harm. The study received ethical approval from Auckland University of Technology Ethics Committee (AUTEC 18/424). All participants gave online informed consent to participate via a Qualtrix survey, followed by verbal consent at the commencement of the recorded interview. This included consent for their data to be analysed and included in research reports. 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Rural and remote communities, which are often the first to be impacted by workforce shortages, struggle to recruit and retain staff (\u003cspan additionalcitationids=\"CR2\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). While targeted investment in academic, political and financial strategies has aimed to increase the numbers of doctors and nurses entering the rural workforce and support them to stay, comparatively little has been done for the professions that make up the Allied Health Scientific and Technical (AHST) collective (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eAllied Health Professionals (AHPs) are clinicians, scientists, therapists and technicians who possess their own unique and specialised expertise in preventing, diagnosing and treating conditions and illnesses (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). In Aotearoa there are more than 40 professional groups included within this broad category (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e), regulated by the Health Practitioners Competence Assurance Act (2003), the Social Workers Registration Act (2003) (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e) or self-regulated (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe challenges facing rural health providers in relation to the recruitment and retention of AHPs have been well documented internationally (\u003cspan additionalcitationids=\"CR11\" citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e), but there is limited research specific to the Aotearoa New Zealand context. In the absence of research exploring factors contributing to the challenges in recruitment and retention of AHPs, organisations have invested in strategies informed by anecdotal \u0026ldquo;evidence\u0026rdquo;, individual viewpoints, or have drawn on data derived in the context of the nursing or medical workforce. Drawing on data from different professional contexts, with different training pathways, regulatory frameworks and scopes of practice presents significant challenges for developing strategies that address the unique needs and perspectives of AHPs. There is a need for research that explores the specific factors that influence AHP\u0026rsquo;s decisions to work and remain in rural settings, to inform the development of more effective, evidence-based approaches to recruitment and retention.\u003c/p\u003e \u003cp\u003eThis research aimed to explore what matters to AHPs in rural and/or remote contexts and how these insights could inform recruitment and retention practices for rural and/or remote health settings. By understanding the attractive aspects of living and working rurally for AHPs, this study sought to develop knowledge that could be applied to strengthen the rural AHP workforce in Aotearoa New Zealand, with potential application for rural health systems globally.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eThis study employed an Interpretive Descriptive methodology, a qualitative approach developed to support researchers exploring practice-oriented phenomena (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). This methodology was chosen for its pragmatic approach to examining challenges within practice settings, with an explicit focus on generating knowledge applicable to real-world clinical settings. The analysis was informed by Reflexive Thematic Analysis (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e), which enabled identification of patterns of meaning within the data.\u003c/p\u003e \u003cp\u003eResearcher Characteristics and Reflexivity\u003c/p\u003e \u003cp\u003eThe primary author (JG) was an Allied Health leader working in a rural location at the time of the research, which provided both insights and potential subjectivities. The researcher engaged in reflective practice throughout the study, examining how her disciplinary background (social work), leadership role, and rural connections influenced her engagement with participants and analysis of data. The researcher\u0026rsquo;s professional role also presented potential conflicts with some participants, which were managed through use of independent interviewers where needed. The research team also included two experienced allied health researchers who served as supervisors: NK, a psychologist and Professor with extensive qualitative and allied health research experience and lived rural experience; and PL, a physiotherapist and Associate Professor with mixed methods and allied health research expertise. Both supervisors contributed to research design, ongoing analysis discussions, and interpretation of findings, bringing complementary perspectives that enhanced the rigour of the research process.\u003c/p\u003e \u003cp\u003eSampling and Recruitment\u003c/p\u003e \u003cp\u003eParticipants were eligible if they were a registered AHP and self-identified as having worked in a rural or remote setting within the last five years, were currently working in such a setting, or were actively seeking to work in one. The decision to use self-identification rather than a formal geographic classification system was deliberate for several reasons. First, at the time of recruitment (2019), the now-established Geographic Classification for Health (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e) had not yet been developed. Second, self-identification allowed participants to articulate their own lived experience of rurality, acknowledging that the experience of rural practice encompasses more than geographic distance alone and includes factors such as service availability, professional isolation, and community context. Third, this approach reduced potential barriers to participation by eliminating the need for participants to disclose specific workplace locations during initial recruitment. This was important for maintaining confidentiality in small rural health networks where individuals might be easily identified.\u003c/p\u003e \u003cp\u003eA purposive sampling approach was used to ensure diversity across professions, geographical locations, ethnicities, and career stages. Potential participants were recruited through multiple channels including social media, organisational newsletters, professional networks and word of mouth. Information about the study was distributed through AHP professional bodies and rural health networks. Potential participants responded to the invitation to take part by completing a brief expression of interest via an online survey which captured key demographic information to support the sampling process.\u003c/p\u003e \u003cp\u003eData Collection\u003c/p\u003e \u003cp\u003eSemi-structured interviews were conducted between July 2019 and December 2021. They were conducted via videoconferencing due to geographical dispersion and the impact of the COVID-19 pandemic, which allowed participants to engage from their preferred location. The interview guide explored participants\u0026rsquo; career journeys, experiences of rural practice, and factors influencing their employment decisions (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). Specific topics included how participants chose their profession, what attracted them to rural practice, experiences of working in rural settings, perspectives on professional development and support, and suggestions for improving recruitment and retention.\u003c/p\u003e \u003cp\u003eInterviews were conducted by the primary author, except where participants were known to the researcher in her professional capacity, in which case they were conducted by NK. Interviews were audio-recorded and lasted between 45\u0026ndash;60 minutes.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eData Analysis\u003c/h2\u003e \u003cp\u003eInterviews were transcribed verbatim and analysed using Reflexive Thematic Analysis (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). Analysis followed six phases: familiarisation with the data, generating initial codes, identifying themes, reviewing themes, defining and naming themes, and reporting. Initial coding was conducted manually on printed transcripts, followed by use of NVivo\u0026trade; software to organise and visualise data. To enhance rigour, the primary author engaged in ongoing reflection through journaling, discussed emergent findings with the research team, and moved iteratively and recursively between individual transcripts, coding and thematic structures.\u003c/p\u003e \u003cp\u003eEthical Considerations\u003c/p\u003e \u003cp\u003eEthical approval was obtained from Auckland University of Technology Ethics Committee (AUTEC 18/424). Informed consent was gained through a two-phase process: initially via the online recruitment survey, and then verbally at the beginning of each interview. Particular attention was paid to managing potential conflicts of interest where participants were employed by the same organisation as the researcher. Anonymity and confidentiality were maintained through removal of identifying information from transcripts and secure data storage.\u003c/p\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eForty-five people initially expressed interest via the online recruitment survey. The final sample of 18 participants were selected to ensure diversity across key characteristics. All participants were female, ranging in age from 23 to 63 years, with most being either 20\u0026ndash;30 years (n\u0026thinsp;=\u0026thinsp;6) or over 50 years (n\u0026thinsp;=\u0026thinsp;6). Participants identified as Pākehā / New Zealander (n\u0026thinsp;=\u0026thinsp;11), Māori (n\u0026thinsp;=\u0026thinsp;4), Samoan (n\u0026thinsp;=\u0026thinsp;1), and from beyond the Pacific (n\u0026thinsp;=\u0026thinsp;2). They represented seven Allied Health professions including social work (m\u0026thinsp;=\u0026thinsp;7), physiotherapy (n\u0026thinsp;=\u0026thinsp;4), music therapy (n\u0026thinsp;=\u0026thinsp;2), occupational therapy (n\u0026thinsp;=\u0026thinsp;2), psychology (n\u0026thinsp;=\u0026thinsp;1), dietetics (n\u0026thinsp;=\u0026thinsp;1) and pharmacy (n\u0026thinsp;=\u0026thinsp;1). Participants were geographically spread throughout Aotearoa, representing areas of differing rurality and with varying proximity to urban centres.\u003c/p\u003e \u003cp\u003eThree interconnected themes that capture what attracts and retains AHPs in rural practice were constructed through analysis. These were Sense of Connection and Belonging, Safe and Supported Practice, and Creating Roles People Want to Come For. These themes were infused with an overarching concept of Fit; a felt sense of being in the right place, professionally and personally. The themes, and their sub-themes are visually represented in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eSense of Connection and Belonging\u003c/p\u003e \u003cp\u003eThe relationships AHPs form with their teams, their communities, and their environment emerged as fundamental to their experience of rural practice. Participants consistently described how these connections acted as critical determinants of their decision to remain in or leave rural roles. Connection and belonging functioned not merely as pleasant additions to workplace satisfaction, but as essential components of professional sustainability in rural contexts. The multi-dimensional nature of these connections, which spanned professional networks, personal relationships, community engagement, and environmental attachment, created an interwoven experience where work and life naturally blended. As one participant explained:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\"We look after each other. Everything is not sweetness and light, but when it is not it's out there in the open, it happens in the team room and not niggling behind people's backs\" (P1).\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eThis theme encompassed the importance of feeling connected to teams, communities and place. This sense of connection often manifested as a deep satisfaction with one's position:\u003c/p\u003e \u003cp\u003e\"I'm thankful to be here... it's good to know you're where you're supposed to be.\" (P2)\u003c/p\u003e \u003cp\u003eWhen these connections were absent or fractured, participants reported that even otherwise attractive roles became unsustainable, highlighting connection and belonging as key factors in retention rather than optional benefits. Three sub-themes were identified: Feeling Cared About, Personal Relationships and In Service.\u003c/p\u003e \u003cp\u003e \u003cb\u003eFeeling Cared About\u003c/b\u003e reflected experiences of being recognised as individuals with unique circumstances and needs. This included practical support for work-life integration and recognition of the rural context.\u003c/p\u003e \u003cp\u003e\u0026ldquo;I can talk to them about you know, how there is no grass growth and have they had to sell off their stock, and it\u0026rsquo;s um, it\u0026rsquo;s a world I am interested in\u0026rdquo; (P1)\u003c/p\u003e \u003cp\u003eParticipants described actions that demonstrated care within teams, such as \u0026ldquo;someone bringing in a crockpot of soup on a chilly day for everyone to enjoy\u0026rdquo; (P1) or \u0026ldquo;loaning bicycles to new graduates and students\u0026rdquo; (P18) to help them experience the local environment. The micro-moments mattered the most; those acts that showed people they were valued as humans, not just as colleagues.\u003c/p\u003e \u003cp\u003e \u003cb\u003ePersonal Relationships\u003c/b\u003e highlighted the significance of forming genuine connections within rural communities. Participants noted how communities and organisations that facilitated social connections for incoming staff were appreciated.\u003c/p\u003e \u003cp\u003e\u0026ldquo;In [my previous rural role] I didn\u0026rsquo;t really experience that, it was a lot harder to make friends. So I definitely think the timing of when you come in, and also having, just the fact that the other people or, the only thing we had in common was that we didn\u0026rsquo;t know the town \u0026hellip; we ended up all getting together coz we were all new to town\u0026rdquo; (P16)\u003c/p\u003e \u003cp\u003eThese relationships were perceived to provide a balance against the \u0026lsquo;always on\u0026rsquo; nature of rural practice and space to maintain professional boundaries, factors that increase the likelihood of AHPs staying and thriving in rural practice settings.\u003c/p\u003e \u003cp\u003e \u003cb\u003eIn Service\u003c/b\u003e captured participants\u0026rsquo; commitment to contributing to their communities beyond their professional roles. For some, this was a strategic part of integration.\u003c/p\u003e \u003cp\u003e\u0026ldquo;I made a decision, I was going to start getting involved in stuff that was here, so my life increasingly became [locally] focused rather than [back in the city] and I started doing voluntary ambulance work and I also met my husband through a flatmate I had at the time, so increasingly, suddenly my world was over here rather than in [the city]\u0026rdquo; (P17)\u003c/p\u003e \u003cp\u003eFor others, particularly Māori participants, service was connected to a sense of obligation to their home communities.\u003c/p\u003e \u003cp\u003e\u0026ldquo;I feel like I owe people at home something and that\u0026rsquo;s quite a motivating factor. I also feel like I fit there, so um, or that I\u0026rsquo;m more useful because I understand people there\u0026rdquo; (P5)\u003c/p\u003e \u003cp\u003eSafe and Supported Practice\u003c/p\u003e \u003cp\u003eSafety and support for rural AHPs extends well beyond traditional risk management frameworks. Participants described multilayered concepts of safety that encompassed not only physical wellbeing but also professional practice, development and wellbeing. For rural practitioners, particularly those working as sole clinicians in geographically isolated areas these dimensions took on heightened significance.\u003c/p\u003e \u003cp\u003e\u0026ldquo;I feel attracted to areas where, when people talk about their jobs, they enjoy the people that they\u0026rsquo;re working with and they feel safe and supported\u0026rdquo;. (P11)\u003c/p\u003e \u003cp\u003eParticipants communicated that rural practice safety was built on strong interprofessional relationships where risk could be shared through mechanisms such as multidisciplinary case reviews and quality planning. They valued environments where their competence was recognised, their learning prioritised and their geographical context understood by leaders and urban colleagues alike. The absence of these elements created not only frustration but also genuine concern about their ability to practice effectively and safely.\u003c/p\u003e \u003cp\u003eThis theme captured the elements that enabled AHPs to practice safely and effectively in rural settings. Three key sub-themes were identified: Connectivity and Technology, Valuing Learning, and Relationship with Leader(ship).\u003c/p\u003e \u003cp\u003e \u003cb\u003eConnectivity and Technology\u003c/b\u003e highlighted both challenges and enablers related to technology access. Participants described limitations such as \u0026ldquo;one laptop for the whole team to share\u0026rdquo; (P1) and areas without mobile coverage, creating safety concerns for lone practitioners. Systems designed and overseen from urban spaces created a sense of the rural practitioners\u0026rsquo; needs being less important.\u003c/p\u003e \u003cp\u003e\u0026ldquo;The infrastructure I think is poor. Provision of infrastructure and the preparation for someone walking into their job is poor compared to say, what I heard reported in [urban centre] for example.\u0026rdquo; (P17)\u003c/p\u003e \u003cp\u003eConversely when technology was provided, it was highly valued: \u0026ldquo;It\u0026rsquo;s actually smart and it works.\u0026rdquo; (P1)\u003c/p\u003e \u003cp\u003e \u003cb\u003eValuing Learning\u003c/b\u003e focused on participants\u0026rsquo; experiences of professional development access and support. Restrictive learning policies were experienced as barriers to professional growth.\u003c/p\u003e \u003cp\u003e\u0026ldquo;I don\u0026rsquo;t want to go to the same entry level talk every year just to count them in my CPD [continuing professional development] folder. Like, I want it to actually be clinically significant\u0026rdquo; (P14)\u003c/p\u003e \u003cp\u003eMany participants perceived inequities compared to medical and nursing colleagues, in terms of both funding and the career pathways professional development enabled.\u003c/p\u003e \u003cp\u003e\u0026ldquo;The nurses take that, become geriatrician nurse specialists, pulmonary nurse specialists, rehab nurse specialists, stroke nurse specialists. [We] aren\u0026rsquo;t sought for those roles at all\u0026rdquo; (P7)\u003c/p\u003e \u003cp\u003e \u003cb\u003eRelationship with Leader(ship)\u003c/b\u003e were particularly significant for remote practice. Trusting relationships with managers enabled independent practice while providing necessary support.\u003c/p\u003e \u003cp\u003e\u0026ldquo;I feel like I\u0026rsquo;ve got that freedom. She does, she definitely trusts me that I\u0026rsquo;ll do the work\u0026rdquo; (P16)\u003c/p\u003e \u003cp\u003eLeaders who personally experienced the rural context, and demonstrated their understanding of rural realities were highly valued.\u003c/p\u003e \u003cp\u003e\u0026ldquo;Within 45 minutes of being here, she had two assessments to do in [a neighbouring town] and we needed a third one to do here in [town]. And she was just like, \u0026lsquo;So what do you guys normally do when you have got this?\u0026rsquo;\u0026rdquo; (P1)\u003c/p\u003e \u003cp\u003eCreating Roles People Want to Come For\u003c/p\u003e \u003cp\u003eIn the competitive landscape of health workforce recruitment across Aotearoa, participants highlighted that rural roles needed to offer more than financial incentives to be considered worthwhile. They described a complex interplay of factors that collectively made a position \u0026lsquo;worth it\u0026rsquo; in terms of personal and professional satisfaction.\u003c/p\u003e \u003cp\u003e\u0026ldquo;You have to work for love rather than money \u0026hellip; if you really enjoy the work then you do end up taking the role\u0026rdquo;. (P4)\u003c/p\u003e \u003cp\u003eFor many participants, the intrinsic rewards of rural practice provided motivation beyond remuneration.\u003c/p\u003e \u003cp\u003e\"I want to stay rural because of all the unique things that makes rural practice what it is.\" (P6)\u003c/p\u003e \u003cp\u003e Participants articulated that a fulfilling role needed to offer professional growth, intellectual stimulation, autonomy and alignment with personal circumstances, all elements that often presented uniquely in rural contexts.\u003c/p\u003e \u003cp\u003eThis theme encompasses the characteristics that made rural roles attractive. Six sub-themes were identified: Recruitment Experiences, Variety of Work, Growth Pathways, Freedom and Scope, Lifespan of Roles, and The Right Role.\u003c/p\u003e \u003cp\u003e\u003cb\u003eRecruitment Experiences\u003c/b\u003e highlighted how first impressions shaped decisions to take rural roles. Participants reported mixed experiences, from slow processes contradicting messages of urgency to thoughtful approaches like offering employment support for partner.\u003c/p\u003e \u003cp\u003e\u0026ldquo;Talking to people about their partners who are moving with them, and what they do and giving them connections\u0026rdquo;. (P3)\u003c/p\u003e \u003cp\u003e \u003cb\u003eVariety of Work\u003c/b\u003e was consistently identified as a significant attraction of rural practice.\u003c/p\u003e \u003cp\u003e\u0026ldquo;I like the variety, so that keeps my head engaged. It means I know a little about a lot, instead of a lot about a little\u0026rdquo; (P6)\u003c/p\u003e \u003cp\u003eWorking across age groups and conditions provided stimulation and professional development.\u003c/p\u003e \u003cp\u003e\u0026ldquo;I also like that \u0026hellip; you know you see a baby and a 100-year old in the same day. So I like the variety and the challenge\u0026rdquo; (P6)\u003c/p\u003e \u003cp\u003e \u003cb\u003eGrowth Pathways\u003c/b\u003e addressed the importance of visible opportunities for professional development and advancement.\u003c/p\u003e \u003cp\u003e\u0026ldquo;If you could do more by being here, so it\u0026rsquo;s a more interesting job on the ground, but as part of that you were supported to maybe get a couple of papers towards a post-grad diploma or you ended up with a post-grad certificate that you could then use towards something else\u0026rdquo; (P17)\u003c/p\u003e \u003cp\u003eParticipants contrasted this with the frustrating experiences where advancement seemed impossible, or invisible.\u003c/p\u003e \u003cp\u003e\u0026ldquo;If I wanted to progress in terms of my career I would need to leave [this town], definitely\u0026rdquo; (P10)\u003c/p\u003e \u003cp\u003e \u003cb\u003eFreedom and Scope\u003c/b\u003e referred to the autonomy and breadth of practice available in rural settings. This freedom and broad scope was both challenging and deeply rewarding for rural AHPs.\u003c/p\u003e \u003cp\u003e\u0026ldquo;I get to work with them in such a diverse way\u0026rdquo; (P8)\u003c/p\u003e \u003cp\u003eParticipants valued being able to work at the edges of their scope, though they noted their skills were not always recognised by urban counterparts, regulators or professional associations.\u003c/p\u003e \u003cp\u003e \u003cb\u003eLifespan of Roles\u003c/b\u003e acknowledged that roles have natural cycles. This influenced expectations about tenure, such as recognising the seasonal flexibility required when AHPs also held farming responsibilities, or for new graduates.\u003c/p\u003e \u003cp\u003e\u0026ldquo;I think at the age and stage they\u0026rsquo;re at it\u0026rsquo;s just that next progression in their careers, they just want to go and do something a bit different somewhere else. That seems to be the norm\u0026rdquo;. (P17)\u003c/p\u003e \u003cp\u003e \u003cb\u003eThe Right Role\u003c/b\u003e captured the importance of alignment between personal circumstances, values and job requirements.\u003c/p\u003e \u003cp\u003e\u0026ldquo;I was attracted back and to the rural areas coz they could offer me what fitted with my family life, and my husband\u0026rsquo;s occupation\u0026rdquo; (P15)\u003c/p\u003e \u003cp\u003eFit: An Overarching Concept\u003c/p\u003e \u003cp\u003eWeaving through all three theses was the concept of Fit, a felt sense of being in the right place at the right time. This encompassed alignment with personal values, connection to community, sustainability of the role to career stage and goals, and compatibility with lifestyle preferences.\u003c/p\u003e \u003cp\u003e\"It's a dream job for \u0026hellip; someone like me.\" (P2)\u003c/p\u003e \u003cp\u003eWhile being born rurally or trained rurally does increase the likelihood of a sense of fit, the participants who fit this profile, and those that did not agreed that the benefits of finding professional, cultural and environmental fit could be achieved without a rural background.\u003c/p\u003e \u003cp\u003eThis sense of Fit appeared to outweigh specific challenges that participants face, and when Fit was absent it often triggered their decision to leave the rural role.\u003c/p\u003e \u003cp\u003e\u0026ldquo;I said to her the other day, \u0026lsquo;would you come back to the hospital?\u0026rsquo; And she was like, \u0026lsquo;way too white (laugh)\u0026rsquo; so and she was just absolutely up front, like, \u0026lsquo;No, there\u0026rsquo;s no fit for me there\u0026rsquo;\u0026rdquo; (P18)\u003c/p\u003e \u003cp\u003eParticipants noted that Fit can be developed and nurtured through supportive leadership, clear and transparent growth pathways, strong professional networks and opportunities to integrate into their communities; components of which can be found across the themes presented above.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study provides new insights into the experiences and perspectives of AHPs working in rural and remote settings in Aotearoa. The findings align with international literature in some respects while offering unique contributions specific to the Aotearoa context.\u003c/p\u003e \u003cp\u003eThe importance of Connect and Belonging resonates with research by Cosgrave (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e) and Kumar, Tian (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e), who similarly found that supportive professional relationships and community integration significantly influence retention. However, our findings particularly highlight the reciprocal nature of these relationships. AHPs both receive and provide care within their communities, and the importance of service as an expression of connection was especially significant for Māori participants.\u003c/p\u003e \u003cp\u003eThe concept of Safe and Supported Practice extends existing literature on professional development access (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e) by emphasising perceived inequities between AHPs and other professions. This perceived hierarchical valuing of workforce groups appears to be a significant factor in AHPs\u0026rsquo; experiences of feeling undervalued, consistent with findings from Walker, Blattner (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). A significant contributing factor to these experiences was what Fors (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e) terms geographical narcissism - the tendency for urban-based professionals and systems to devalue rural health and expertise. This manifested in how decisions were made without understanding rural contexts, how professional development was structured, and how rural AHPs felt their skills were perceived by urban counterparts, further compounding their sense of being undervalued within health system hierarchies.\u003c/p\u003e \u003cp\u003eOur findings around Creating Roles People Want to Come For challenge some common assumptions about rural recruitment. Contrary to literature emphasising financial incentives (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e) or lifestyle factors such as outdoor activities (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e), our participants placed greater emphasis on professional aspects such as scope of practice, variety and growth opportunities. This suggests that professional satisfaction may be a more powerful motivator than previously recognised.\u003c/p\u003e \u003cp\u003eThe overarching concept of Fit offers a novel contribution to understanding rural AHP workforce issues. While previous research has examined various aspects of \u0026lsquo;fit\u0026rsquo; (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e), our study suggests a more holistic conceptualisation that integrates professional, personal and place-based elements. This aligns with recent research on place attachment and belonging-in-place (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e), and extends these concepts by emphasising how fit operates simultaneously across multiple dimensions.\u003c/p\u003e \u003cp\u003eOur findings suggest that Fit is not merely a static attribute but a dynamic and relational construct that can be cultivated over time. Participants described how their sense of Fit evolved through meaningful engagement with communities, development of professional confidence, and acquisition of context-specific knowledge. This challenges simplistic recruitment models that rely primarily on rural origin or training as predictors of rural retention (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e). Instead, it suggests that creating conditions where AHPs can develop and experience Fit across multiple dimensions may be more effective.\u003c/p\u003e \u003cp\u003eFurthermore, Fit appears to function as both a protective factor during challenges and a threshold concept for retention decisions (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e). When Fit was strong, participants described weathering significant workplace challenges; when it deteriorated, departure became inevitable. This conceptualisation offers a useful framework for understanding the complex interplay of factors that influence AHPs\u0026rsquo; decisions to remain in or leave rural settings and could inform more nuanced approaches to workforce planning.\u003c/p\u003e\n\u003ch3\u003eStrengths and Limitations\u003c/h3\u003e\n\u003cp\u003eThis study has several strengths and limitations. Strengths include the diversity of professions, geographical locations, and cultural backgrounds represented. This study is also the first of its kind in Aotearoa, providing valuable context-specific insights previously absent from the literature. The Interpretive Descriptive methodology (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e) enabled robust analysis while maintaining focus on practice applications. Limitations include that all participants identified as female, limiting insights into potential gender differences. Additionally, self-identification of rural practice rather than using geographic classification such as Whitehead, Davie (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e)\u0026rsquo;s Geographical Classification for Health may have affected sample composition.\u003c/p\u003e\n\u003ch3\u003eImplications for Practice\u003c/h3\u003e\n\u003cp\u003eThe findings have several implications for rural health organisations, line managers, recruiters, professional bodies and educators. Successful recruitment and retention strategies should address all three thematic areas identified: fostering connection and belonging, ensuring safe and supported practice, and creating attractive roles.\u003c/p\u003e \u003cp\u003ePractically, this means developing recruitment processes that reflect organisational values, facilitating social and professional networks for new staff, ensuring appropriate resources and technology, providing equitable access to professional development and creating visible growth pathways. Additionally, organisations should examine how they value and promote AHP contributions, challenging hierarchical structures that privilege medical and nursing perspectives (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e).\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis study provides significant insights into the experiences and perspectives of AHPs working in rural and remote settings in Aotearoa New Zealand. The findings highlight that successful recruitment and retention requires attention to both professional and personal factors, with particular emphasis on creating environments where AHPs feel valued, supported to develop their practice and connected to their communities.\u003c/p\u003e \u003cp\u003eThe overarching concept of Fit offers a useful framework for understanding how various elements interact to influence AHPs\u0026rsquo; decisions to work and remain in rural settings. This supports a shift from relying on stereotypical rural attractions or financial incentives towards creating meaningful roles and supportive environments that enable AHPs to contribute their full potential.\u003c/p\u003e \u003cp\u003eRather than viewing the rural AHP workforce challenge as primarily one of recruitment, this research suggests that creating conditions where AHPs experience fit across multiple dimensions will naturally enhance both recruitment and retention. Further research could explore how these findings might be implemented and evaluated in practice settings and further examine the concept of Fit as it relates to rural health workforce development.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eAHPs\u0026nbsp; Allied Health Professionals\u003c/p\u003e\n\u003cp\u003eCOVID-19 Coronavirus Disease of 2019\u003c/p\u003e\n\u003cp\u003eCPD \u0026nbsp;Continuing Professional Development\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe are grateful to the 18 AHPs who gave up their time to participate in the research.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eJG designed the study with support from PL and NK; JG and NK were involved in the data collection; JG analysed and interpreted the data with support from NK and PL; JG drafted the manuscript with support from NK and PL. All authors approved the submitted version.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Availability\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe qualitative datasets generated during this study are not publicly available due to their co-constructed nature between researcher and participants, the sensitive personal narratives contained within, and ethical constraints. Participants consented to share their experiences with the assurance that raw data would remain confidential to the research team. The contextual and potentially identifiable nature of in-depth qualitative data makes complete de-identification challenging whilst preserving data integrity.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWhile the Declaration of Helsinki primarily addresses medical research conducted by physicians and is therefore not directly relevant to this qualitative study; exploring allied health professional perspectives, it has adhered to the core ethical principles regarding human subjects research, including informed consent, voluntary participation, confidentiality, and minimisation of harm. The study received ethical approval from Auckland University of Technology Ethics Committee (AUTEC 18/424). All participants gave online informed consent to participate via a Qualtrix survey, followed by verbal consent at the commencement of the recorded interview. This included consent for their data to be analysed and included in research reports.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo funding was received for this research\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting Interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eBuykx P, Humphreys J, Wakerman J, Pashen D. Systematic Review Of Effective Retention Incentives For Health Workers In Rural And Remote Areas: Towards evidence-based policy. Australian Journal of Rural Health. 2010;18(3):102-9.\u003c/li\u003e\n\u003cli\u003eCarson DB, Schoo A, Berggren P. The \u0026apos;Rural Pipeline\u0026apos; And Retention Of Rural Health Professionals In Europe\u0026apos;s Northern Peripheries. Health Policy. 2015;119(12):1550-6.\u003c/li\u003e\n\u003cli\u003eChisholm M, Russell D, Humphreys J. Measuring Rural Allied Health Workforce Turnover And Retention: What are the patterns, determinants and costs? Australian Journal of Rural Health. 2011;19(2):81-8.\u003c/li\u003e\n\u003cli\u003eGeorge JE, Larmer PJ, Kayes N. Learning From Those Who Have Gone Before: Strengthening the rural Allied Health workforce in Aotearoa New Zealand. Rural and Remote Health. 2019;19(3):1-9.\u003c/li\u003e\n\u003cli\u003eMak K-HM, Kippist L, Sloan T, Eljiz K. What Is the Professional Identity of Allied Health Managers? Asia-Pacific Journal of Health Management. 2019;14(1):58-67.\u003c/li\u003e\n\u003cli\u003eMinistry of Health. Allied Health online: Ministry of Health; 2021 [Available from: https://www.health.govt.nz/about-ministry/leadership-ministry/allied-health.\u003c/li\u003e\n\u003cli\u003eHealth Practitioners Competence Assurance Act, Stat. 2003 No 48 (18 September 2003, 2003).\u003c/li\u003e\n\u003cli\u003eSocial Workers Registration Act, Stat. 2003 No 17 (2003).\u003c/li\u003e\n\u003cli\u003eWalker SM, Kennedy E, Nixon G, Blattner K. The Allied Health Workforce Of Rural Aotearoa New Zealand: a scoping review. Journal of Primary Health Care. 2022;14(3):259-67.\u003c/li\u003e\n\u003cli\u003eCosgrave C. Context Matters: Findings from a Qualitative Study Exploring Service and Place Factors Influencing the Recruitment and Retention of Allied Health Professionals in Rural Australian Public Health Services. International Journal of Environmental Research and Public Health. 2020;17(16):5815.\u003c/li\u003e\n\u003cli\u003eKumar S, Tian EJ, May E, Crouch R, McCulloch M. \u0026ldquo;You get exposed to a wider range of things and it can be challenging but very exciting at the same time\u0026rdquo;: enablers of and barriers to transition to rural practice by allied health professionals in Australia. BMC Health Services Research. 2020;20(1):1-14.\u003c/li\u003e\n\u003cli\u003eO\u0026apos;Toole K, Schoo A, Stagnitti K, Cuss K. Rethinking Policies For The Retention Of Allied Health Professionals In Rural Areas: A social relations approach. Health Policy. 2008;87(3):326-32.\u003c/li\u003e\n\u003cli\u003eThorne S. Interpretive Description: Qualitative research for applied practice. New York: Routledge; 2016 2016.\u003c/li\u003e\n\u003cli\u003eBraun V, Clarke V. Thematic Analysis: A practical guide. London: SAGE Publications Ltd; 2022.\u003c/li\u003e\n\u003cli\u003eWhitehead J, Davie G, De Graaf B, Crengle S, Fearnley D, Smith M, et al. Defining rural in Aotearoa New Zealand: a novel geographic classification for health purposes. New Zealand Medical Journal. 2022;135(1559):24-40-.\u003c/li\u003e\n\u003cli\u003eGeorge J. Understanding the Complexities of Recruitment and Retention of Allied Health Professionals in Rural Health Settings. Tuwhera: Auckland University of Technology; 2023.\u003c/li\u003e\n\u003cli\u003eCosgrave C, Maple M, Hussain R. An Explanation Of Turnover Intention Among Early-Career Nursing And Allied Health Professionals Working In Rural And Remote Australia \u0026ndash; findings from a grounded theory study. Rural and Remote Health. 2018;18(4511).\u003c/li\u003e\n\u003cli\u003eKeane S, Smith T, Lincoln M, Fisher K. Survey Of The Rural Allied Health Workforce In New South Wales To Inform Recruitment And Retention. The Australian Journal of Rural Health. 2011;19(1):38-44.\u003c/li\u003e\n\u003cli\u003eWalker SM, Blattner K, Nixon G, Koroheke Rogers M, Kennedy E. What does it mean to be an allied health professional working in rural Aotearoa New Zealand? A qualitative study. Australian Journal of Rural Health. 2023.\u003c/li\u003e\n\u003cli\u003eFors M. Geographical narcissism in psychotherapy: countermapping urban assumptions about power, space, and time. Psychoanalytic Psychology. 2018;35(4):446.\u003c/li\u003e\n\u003cli\u003eSmith T, Cooper R, Brown L, Hemmings R, Greaves J. Profile Of The Rural Allied Health Workforce In Northern New South Wales And Comparison With Previous Studies. Australian Journal of Rural Health. 2008;16(3):156-63.\u003c/li\u003e\n\u003cli\u003eKeane S, Lincoln M, Smith T. Retention Of Allied Health Professionals In Rural New South Wales: A thematic analysis of focus group discussions. BMC Health Services Research. 2012;12(1):175-.\u003c/li\u003e\n\u003cli\u003eCampbell N, Eley DS, McAllister L. How Do Allied Health Professionals Construe the Role of the Remote Workforce? New insight into their recruitment and retention. PLoS One. 2016;11(12):1-15.\u003c/li\u003e\n\u003cli\u003eConomos AM, Griffin B, Baunin N. Attracting Psychologists To Practice In Rural Australia : The role of work values and perceptions of the rural work environment. The Australian Journal of Rural Health. 2013;21:105-11.\u003c/li\u003e\n\u003cli\u003eGillespie J, Cosgrave C, Malatzky C, Carden C. Sense of place, place attachment, and belonging-in-place in empirical research: A scoping review for rural health workforce research. Health \u0026amp; Place. 2022;74:102756.\u003c/li\u003e\n\u003cli\u003eDunbabin J, Levitt L. Rural Origin And Rural Medical Exposure: Their impact on the rural and remote medical workforce in Australia. Rural and Remote Health. 2003;3(212).\u003c/li\u003e\n\u003cli\u003eSkinner TC, Semmens L, Versace V, Bish M, Skinner IK. Does undertaking rural placements add to place of origin as a predictor of where health graduates work? Australian Journal of Rural Health. 2022;30(4):529-35.\u003c/li\u003e\n\u003cli\u003eYusliza MY, Noor Faezah J, Ali Na, Mohamad Noor NM, Ramayah T, Tanveer MI, et al. Effects of supportive work environment on employee retention: the mediating role of person\u0026ndash;organisation fit. Industrial and commercial training. 2021;53(3):201-16.\u003c/li\u003e\n\u003cli\u003eRees GH. Health workforce governance and professions: a re-analysis of New Zealand\u0026apos;s primary care workforce policy actors. BMC Health Services Research. 2023;23(1):1-13.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Allied Health Professionals, rural health, recruitment, retention, workforce, Aotearoa New Zealand","lastPublishedDoi":"10.21203/rs.3.rs-6844944/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6844944/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eRural and remote communities in Aotearoa New Zealand face significant challenges in recruiting and retaining Allied Health Professionals (AHPs). While targeted investment exists to increase the numbers of doctors and nurses entering the rural workforce, comparatively little has been done for the professions that make up the Allied Health Scientific and Technical collective. This study aimed to explore factors that influence AHPs\u0026rsquo; decisions to work and remain in rural settings.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eDrawing on Interpretive Descriptive methodology, semi-structured interviews were conducted with 18 AHPs from diverse professions, ethnicities and geographical locations across Aotearoa who had experience working in rural and/or remote settings. Interviews explored participants\u0026rsquo; career journeys, their experiences of rural practice, and factors influencing their employment decisions. Data were analysed using Reflexive Thematic Analysis.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThree key themes were constructed: (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) Sense of Connection and Belonging, highlighting the importance of feeling connected to teams, community and place; (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) Safe and Supported Practice, emphasising appropriate resources, professional development, and leadership relationships; (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e) Creating Roles People Want to Come For, encompassing recruitment experiences, variety of work, growth pathways and scope of practice. These themes were infused with a concept of \u0026lsquo;Fit\u0026rsquo;, a felt sense of being in the right place, personally and professionally.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eThis study provides insights into the perspectives of rural AHPs in Aotearoa New Zealand. Findings suggest that successful recruitment and retention requires attention to both professional and personal factors, with particular emphasis on creating environments where AHPs feel valued, supported to develop their practice, and connected to their communities. These insights can inform the development of targeted strategies to strengthen the rural AHP workforce.\u003c/p\u003e","manuscriptTitle":"Understanding the Complexities of Recruitment and Retention of Allied Health Professionals in Rural Health Settings: A qualitative study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-06-23 05:36:16","doi":"10.21203/rs.3.rs-6844944/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-08-26T01:37:13+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-08-04T07:15:45+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-07-20T07:10:30+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-07-19T03:24:08+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"74544671034901695359268854035936418578","date":"2025-07-10T20:34:03+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"146675261738736768002007196265127348565","date":"2025-07-09T22:09:06+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"299749221948019469424671213059195091367","date":"2025-07-08T17:20:25+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"146889107435385257325092266003144191872","date":"2025-06-17T09:17:14+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-06-17T04:30:41+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-06-15T23:32:20+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-06-13T23:18:20+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Health Services Research","date":"2025-06-13T23:15:34+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"78f8f46c-17f2-4f41-8188-18860186c683","owner":[],"postedDate":"June 23rd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-02-02T16:04:06+00:00","versionOfRecord":{"articleIdentity":"rs-6844944","link":"https://doi.org/10.1186/s12913-026-14083-3","journal":{"identity":"bmc-health-services-research","isVorOnly":false,"title":"BMC Health Services Research"},"publishedOn":"2026-01-30 15:57:57","publishedOnDateReadable":"January 30th, 2026"},"versionCreatedAt":"2025-06-23 05:36:16","video":"","vorDoi":"10.1186/s12913-026-14083-3","vorDoiUrl":"https://doi.org/10.1186/s12913-026-14083-3","workflowStages":[]},"version":"v1","identity":"rs-6844944","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6844944","identity":"rs-6844944","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}