Thirteen residents in their final year of training in the specialty of family and community medicine and nursing at the Central Catalonia Teaching Unit participated in the study. Table 1 shows the main sociodemographic characteristics of the participants. Of those interviewed, 5 (38%) have stayed to work in central Catalonia.
Table 1
Participant | Profession | Age | Location of previous studies | Priority in the choice of specialty |
P1 | nurse | 29 | Murcia (Spain) | 2 |
P2 | nurse | 26 | Girona (Spain) | 1 |
P3 | nurse | 25 | Tenerife (Spain) | 2 |
P4 | nurse | 25 | Almeria (Spain) | 1 |
P5 | doctor | 29 | Barcelona (Spain) | 2 |
P6 | doctor | 29 | Sant Cugat (Spain) | 2 |
P7 | doctor | 31 | Zaragoza (Spain) | 2 |
P8 | doctor | 29 | Barcelona (Spain) | 1 |
P9 | doctor | 34 | Parma (Italy) | 1 |
P10 | doctor | 28 | Las Palmas de Gran Canaria (Spain) | 1 |
P11 | doctor | 45 | Iran (Iran) | 2 |
P12 | doctor | 28 | Seville (Spain) | 1 |
P13 | doctor | 28 | Barcelona (Spain) | 1 |
The results of this study were based on six themes that emerged in the thematic analysis of the data (Table 2).
Table 2
Theme | subtheme |
Factors related to the training programme | Individualised training Mentoring process Shifts and on-call duty |
Factors related to the characteristics of the family and community specialty | Previous training Generalist specialty Doctor-nurse/patient relationship Patient-centred model Teamwork Too much bureaucracy Short patient time Disrepute Little professional development |
Factors related to the concept of rural life | Living in a village Being the village doctor or nurse |
Family and relational factors | Family ties Having a partner |
Economic and resource factors | Economic incentives Cost of living |
Factors related to recruitment and job opportunities | Types of contracts Nursing specialty and job exchange Supply planning |
Factors related to the training programme.
Participants highlighted advantages of training in a rural area such as individualisation in learning.
I chose Central Catalonia as an option: I had been told that the training of doctors was good because it has a smaller hospital, and the family resident had more prominence in the different specialties and that made me decide to come. P5
The opportunities they had for being in a teaching unit with few residents.
Because it is small and rural, I am the only resident, and the teaching is at an individual level, and you see everything in first person. There is very good feedback that perhaps if there are more residents is not so personalised, and you can get involved and participate a lot in the activities of each service where you go. P5
You get individual treatment - I’m not just nurse number 130 but I’m XX. And I am valued and empowered. P2
The majority of residents, both doctors and nurses, positively assessed the mentoring process for their learning.
I have been fortunate to have a very good tutor on a personal and professional level. I have learnt a lot and she has given me a lot of confidence to discuss any questions I have. P5
But they also explained how this relationship can influence retention.
If you don't have a good relationship with the tutor, if you have a fairly negative experience, that makes you not want to stay. P6
Among the learning activities in the context of professional practice, the shifts in different hospital clinical units were highly appreciated by both doctors and nurses.
You learn a lot on shifts, it completes your training. And then on a day-to-day basis, because you've seen so much, you can deal with it. P1
They valued the purpose of the shifts to better understand the area's resources.
We have to go through the different services because we have to know what is acute or what is chronic and those that can be made acute, what we can do from the primary care centre. In the end we are the ones who refer the different services, or we can also solve problems in the primary care centre. P5
They also pointed out that doing hospital on-call duty provided them with security in order to treat critical illnesses in rural areas.
Because then if I find a serious case in the primary care centre, we have a little more back-up. Because few come to me, but when they do, it's good to know what to do. P6
Factors related to the characteristics of the family and community specialty and personal motivations
The participants explained their reasons for choosing the family specialty. All the nurses had studied primary care subjects during their nursing degree curriculum, and they explained how this training experience was crucial when choosing their specialty.
I was going to study mental health; it was my goal but for my last internship in my fourth year I went to a rural primary care centre and there I fell in love with primary. P2
On the other hand, not all the doctors had taken specific primary care subjects during their university training and considered that this could later influence them in not choosing this specialty.
You have Cardiology, Nephrology, and Digestive Medicine, but there is no Family Medicine. If everything that it covers were really explained, there would not be this kind of rejection, in inverted commas. I have to say that family medicine is the last thing to be chosen because it is for the one who has had a bad result in the internal medicine residency. P8
And as a result, they said that a subject within the curriculum would help to have more doctors who would want to do the specialty.
If a course of study were made, we would lose the idea that the family doctor is the doctor who does not have a specialty because he/she touches upon everything and knows nothing in depth. P8
Another characteristic that the participants considered was the disrepute of family doctors and how this aspect may influence the poor recruitment of family professionals.
I think what has gone wrong is the belief that good doctors work in the hospital and bad doctors stay in primary care. P8
But despite the discredit they believe the specialty has among the medical community and also socially, this did not deter them from choosing the specialty.
There really is a lack of prestige, and I think it comes from the previous era, when people finished their degree and were already primary care doctors without a specialty. And people have kept this particular idea. It is not global, not everyone thinks so, but there is a kind of thinking that the primary care doctor is the idiot who did not want to do a specialty. P10
Doctors mentioned that the salary was not a motivating factor in choosing the specialty.
It is very clear to me that I did not study family medicine for the money that is earned. P3
Therefore, despite the fact that many of them already had previous experience in primary care and motivations for choosing the specialty, during the residency period they detected characteristics of primary care that could be related to retention and willingness to practice, such as the systemic approach.
I wanted a specialty that covered a lot, not focusing on being an eye doctor, but something of the whole body, not just centred around one area. The variability that family medicine gives you, that you don't know what you are going to get the next day. I like variety. P10
They discovered the scope of primary care as a specialty
In family medicine you are lucky enough to have the chance to specialise in one thing or another. And then you also have all this part of minor surgery techniques, injections and ultra-sound scans, which is also something this allows you to do. P8.
Such as the independence of the professional,
We also have our independence to do things. So that's what I take away most - I have been surprised in that sense. P3
And longitudinality
I must emphasise the importance of the relationship you have with the patient and the importance of following up with the patient, of knowing what has happened to them. I find this very important for health care, because if you give them medication but the next day something happens because of the medication, for example you give them an antihypertensive, because they have low blood pressure, cramps in their legs or they sweat at night.... you can be reached, and you are accessible for them to call and say: look, I have not been doing well or I want to stop taking the pills. Well, that is very important for you to know. P5
They specified the importance of the doctor-patient relationship in primary care and of the holistic perspective of the person.
I have seen the doctor-patient relationship at a later stage. The way you relate to the patient and know their family is very important. At a social level this has been more of a discovery now in the residency. P13
They also value the environment as an aspect that favours the relationship.
Seeing the environment where the patient lives helps you to understand more about what they sometimes explain. When you see them in the environment where they live you can understand the difficulty, the other person's problem, the experience of living with a disease, etc. I believe that what makes family medicine special is knowing the patient's environment. P8
Both doctors and nurses emphasised the patient-centred model in the family and community setting.
I have seen that individualisation is kind of the essence because you know that not everything is as mechanical or as easy as the clinical practice guideline says, and it is more about adapting to the person and the context. P13
Furthermore, during the residency both nurses and doctors talked about the need to improve teamwork.
I think teamwork is very important for me. We are a very individualistic group, especially doctors, and we do not know much about teamwork. I have seen now that the work is very hierarchical. In other words, there has been teamwork, but more than teamwork, it has been more group work. Something that is essential, that we need to incorporate in our day-to-day life and even more so in primary school. It is about sharing knowledge and different visions. We should be more decisive as a team, and I think there is still a lot to do. P13
They also found negative aspects in daily tasks such as the bureaucratic part of being a family doctor.
The bureaucratic part consumes a lot of your time and takes it away from the care part, and then you are also the gateway to all the frustrations of the patient with all the other specialists: if I have not been called by the traumatologist, I’ll take it out on you later. The ophthalmologist should have asked me for it, and he didn't so I’ll take it out on you. And then there’s the issue of work discharges. I can't deal with it. It's beyond me. P12
Or they felt limited by the little time that can be devoted to each patient.
In practice, I have found the time per patient to be totally insufficient. I find it practically impossible to monitor chronicity in 10 minutes. It gives me the feeling that I'm kind of postponing things I don't know for later, for when I have time to look at the ones I'm not resolving because I don't have time to think anymore. For me, it creates discomfort in my day-to-day life to know that I am not doing things right and that I no longer have time to deal with things calmly. P12
Factors related to the concept of rural life
The participants talked about their experience of integrating and adapting to the area where they have been trained.
Here in Osona I have integrated very well, and I feel very comfortable, both with the professional team and on a personal level and that's why I would like to stay. P5
Most come, spend the four years and eventually integrate with the other residents but not with the community, not too much. P6
They mention that the rural lifestyle may appeal to some of the participants and identify the characteristics of rural medicine and nursing as attractive.
I like it. I prefer rural areas over the city. I suppose that because of the proximity of the patients and because it is a small team there tends to be more communication. P6
I prefer the idea of an urban area. Maybe the kind of people you have to deal with isn't ideal, but I don't see myself working alone in a rural area. I like the idea of having more co-workers, having a fairly large centre where there are more people and being able to talk about things. P9
Family and relational factors
One aspect that stood out notably was the family tie as a reason for doctors and nurses not staying and returning home.
They leave because they have family there. I understand it. P8
The issue of not finding a partner in the area also stands out.
Either you marry someone from here or you won't get them to stay. It is the link that would make them stay, but that is very difficult. P6
Economic and resource factors
Participants stated that they have no economic incentives to retain them in rural areas.
Perhaps they could do it, I don’t know, as some places in the south of France do: For five years you don't pay taxes, they offer you a house to stay in and if you have any problem with the issue of the offices, they help you with everything. P8
In addition, for some of them coming from other areas, they find that the area where they have studied is more expensive compared to the area they came from.
Then the rent here is super expensive. Life is expensive here compared to where I am from, and the salary is not very high either. If you equate it with what you spend on rent and everything, it's not that much. For example, in Murcia they do earn much more. P1
We cannot have job stability
I need stability and to know that I am going to have a medium or long-term contract that will allow me to sort out my life, not to be waiting. P3
Factors related to recruitment and job opportunities
Participants noted that deciding on the near future was a complex and uncertain process. This organisational situation put pressure on them to decide and was stressful.
The data showed a difference between medical and nursing staff. For example, doctors had more defined and clear contracts with more stable contractual conditions compared to nurses.
In principle the offer is good, it is interim, and from what I have felt nursing is not that lucky. Nurses have very small contracts and are constantly having to see if they will be renewed, possibly because of the need for more medical professionals who offer us better conditions. P5
For nurses, the job offers were nil
I would like to stay in the area where I am in training right now, but I am not being offered anything. I feel very sad. P4
or with short and uncertain contracts
Maybe you have a chance to stay, but we can't offer you a very big contract... they don't give you much hope either and you have to organise your life. I have to pay the rent and not wait to see if something falls into my lap. P3
The nurses perceived a dichotomy between initial expectations and the job offer after completion of the residency. They experienced it as a loss of talent and demotivation.
They are doing it wrong because we are all leaving. They should act in your favour because they have already taught you and they have trained you. That's worth money and, in the end, no, they don't take you into account as they should. P1
And loss of economic resources and lack of expert appraisal.
I don’t understand it, because you have already been trained. You have more knowledge. And they don't value it, they give you a contract just like that person without a specialty. It's a waste of talent and money. P1
Also, the time lag between the job offer and having to make a decision limited retention and declining the offer.
Maybe people will leave anyway, but I think that a percentage would stay if they had that time, let's say, to make a decision, because it's not like buying a t-shirt in one colour or another. I mean, it’s choosing your future career and where you are going to live. P3
Also, some doctors stated that not being able to stay in the unit where they had been trained reduced the chances of retention.
Our management does not offer for us to stay in our health centre, but in any centre in the region. And this is a limiting factor. I think that if they offer you your own centre and your familiar environment it would be much better, but to go to a health centre that you don't know, it means you go to your own city and start there again. P10
A negative aspect for nurses was the lack of specialty assessment and not having a specific pool of specialists to fill positions.
We do not have a specific pool, but it is true that I believe that this assessment, this plus, should be given. I think that should be considered when it comes to actually offering something at the end. P3
This experience led the nurses to opt for other autonomous communities where the specialty is valued within the labour pool or where there is a specific pool of specialists.
Many of the resident nurses end up returning to their place of origin or to other autonomous communities in Spain where the specialty is valued both economically and when it comes to opting for a position or a longer contract. P3
They come back also because there are communities where nursing salaries are much higher. So, if they do have a community where they also have a specific pool, they will hire you earlier and with a better salary and you will also be close to home P2.