Faculty Retention in Medical Schools of Iran: A Qualitative Content Analysis

Background and purpose: Faculty are the cornerstone of academic medicine and are the important assets for any institution offering higher education. The recruitment and retention of capable faculty are essential to maintain and improve the quality of education and research performance of universities.The purpose of the present study is to discover the views, experiences, and attitudes of faculty to identify the reasons for the attrition and the retention of faculty. Methods: Using the qualitative content analysis, a total of 20 transferred faculty or those who requested to be transferred participated in the study. Data were collected using semi-structured interviews in face to face and by telephone. To measure the trustworthiness of the data, we used the four components of Credibility, transferability, dependability, and confirmability proposed by Lincoln and Guba. Results: The findings were divided into 3 categories and 14 sub-categories: the first category was the retention enforcers, including 4 sub-categories of facilitated communication, distance, gaining experience, and support of authorities; the second category was the retention threats, including 6 subcategories of social infrastructures, individual dimension, occupational dimension, economic dimension, sense of respect, and executive management dimension; and the third category was the retention strategies, including 4 sub-categories of the process of recruiting and promotion, connecting with major universities, facilitating scientific growth, and fulfilling the future needs. Conclusion: Several factors play role in the retention of faculties in medical schools. Authorities can create a more positive environment by devising a suitable reward system, supporting academic activities, and increasing the level of practical autonomy of faculty, to develop a sense of belonging among the workforce, and reduce the intention to transfer of their human resources. qualitative The of the qualitative to describe discover a phenomenon, problem and examine a wide range of questions related to experiences, knowledge, attitudes, emotions, and perceptions of individuals (12). In the qualitative study, the main approach is purposive sampling (13). In this research, participants were selected purposefully to obtain the highest level of information. They were the transferred faculty or those who had requested to be transferred. The purpose to identify their experiences, tendencies, and views on the reasons for their retention and attrition. The data collection then and its presented to them and their the were obtained. Arrangements on time place for Out of 20 16 were face to face and 4 were telephone interviews. At the beginning of the while the participants were their information be treated strictly confidential. The sample size was extended for the theoretical saturation Participants were twenty transferred or upon transfer faculty. Interviews lasted 45–60 minutes. They started with the general question “What do you think is the reason for the attrition of faculty in academic medicine?”, and continued with the questions such as are the factors affecting the retention of faculty in medical schools?”, are your suggested strategies for encouraging faculty to remain at small schools?”, and follow up questions.


Background
Faculty are the cornerstone of education in medical science (1) and are important assets for any institution offering higher education (2). Determining the place and rank of universities in the national and international arena is also dependent on the faculty (3).
On the other hand, the recruitment and retention of talented faculty are also crucial to maintain and improve the quality of education and research performance of universities (4). One of the major challenges faced by small medical schools is the recruitment of faculty, which, due to the complexity and difficulty of its process, puts individuals and institutions under pressure (1). A much bigger challenge is the transfer or attrition of faculty. According to a study conducted in the United States, out of ten faculty, five are transferred over ten years (5). In their study, Fang and Bednash (2014) reported that 11.8% of full-time faculty who worked in 2010 left their full-time jobs by 2011. (6).
Concerns about the retention of faculty are usually due to the fact that the transfer of faculty imposes heavy costs upon universities, such as the loss of recruitment investment, recruiting substitute faculty, and a long recruitment process. Also, the negative impact of the substitution and early transfer of faculty causes an interruption in education and counseling, which has extensive consequences to the academic system (1,7). On the other hand, the criteria for retention of faculty are often vague and there is no transparent mechanism for retaining faculty at their recruited university (2). However, various studies have been conducted in higher education institutions to identify the factors affecting the retention of faculty. In this regard, Soomro and Ahmad (2013) suggested some solutions in the field of education, research, and community services to retain the faculty (2). Breslow's study, on the other hand, showed that some faculty moved for personal reasons, unsupported working environments, and holding better positions (8). Lee (1982) also found in his study that the attrition of faculty for personal reasons, job dissatisfaction, and low salary at the state universities was slightly higher than that of the schools of social and technical sciences (9). Nonetheless, structured programs seem to be effective in faculty development, while motivating and enhancing the quality of students' learning and progress, leads to the retention of faculty. Ries et al.
(2012), in the National Center of Leadership in Academic Medicine (NCLAM) at the University of California, identified that programs including professional development workshops, strategic planning, individualized academic performance counseling, mentoring with a senior faculty member focused on a professional development, and network-building with other faculty to promote assistant professors in health sciences has had a significant impact on the retention of new assistant professors (1). Locke's study also showed that faculty of different regions have different attitudinal and behavioral patterns that are shaped by the distinct epistemology, organizational commitment, and social relationships (10), which can be very effective in the retention of faculty. Thus, universities need to design and implement a program for the complex process of recruiting faculty to maintain their human resources and reduce the negative consequences of faculty transfer.
In Iran, the attrition of faculty in small schools is one of the major problems in academic medicine. It seems that despite the international and national interest in the retention of faculty, few studies have been conducted on the retention of faculty at the medical universities of the country. Undoubtedly, the examination of the effective methods in the retention of faculty plays an important role in improving educational and research status. Therefore, it is crucial to study the factors affecting the retention and attrition of faculty.
Due to the different attitudinal and behavioral patterns that are influenced by multiple cultural factors and can lead to the different faculty views about the desire to move, the purpose of the present study is to discover the views, experiences, and attitudes of faculty to identify the reasons for the attrition and retention of faculty.

Participants and study design
The present study was conducted using qualitative content analysis. These kinds of studies are also referred to as qualitative descriptive studies (11). The main purpose of the qualitative studies is to describe or discover a phenomenon, problem or subject, and examine a wide range of questions related to experiences, knowledge, attitudes, emotions, and perceptions of individuals (12). In the qualitative study, the main approach is purposive sampling (13). In this research, participants were selected purposefully to obtain the highest level of information. They were the transferred faculty or those who had requested to be transferred. The purpose was to identify their experiences, tendencies, and views on the reasons for their retention and attrition. The data collection process was that the participants were first identified and contacted to gain participation, then explanations regarding the research and its goals presented to them and their consent to participate in the study were obtained. Arrangements were then made on the appropriate time and place for the interview. Out of 20 interviews, 16 were face to face and 4 were telephone interviews. At the beginning of the interview, to obtain informed consent, we request permission to record the interview, while the participants were assured that their personal information would be treated strictly confidential. The sample size was extended for the theoretical saturation (14). Participants were twenty transferred or upon transfer faculty. Interviews lasted 45-60 minutes. They started with the general question "What do you think is the reason for the attrition of faculty in academic medicine?", and continued with the questions such as "What are the factors affecting the retention of faculty in medical schools?", "What are your suggested strategies for encouraging faculty to remain at small schools?", and follow up questions.
To analyze the data, a qualitative content analysis was used with the deductive reasoning approach. To this end, the data were read up until the saturation occurred and semantic units extracted. In the next stage, after summarizing the units, the condensed semantic units were extracted that were short in terms of the number of words and semantically equivalent to the semantic units. Then the semantic units with the semantic similarity were converted into code by getting the label. At this stage, we used peer-checking to ensure the trustworthiness of the interpretation of the data. The number of primary codes was 123, which reduced to 90 after merging similar codes and removing identical ones.
This stage was revised several times with the views of the contributors. In the next stage, after comparing the codes, they were divided into sub-categories. The next stage included modifying the subcategories map. The subcategories were constantly compared and reviewed during the process so that some of them, based on common or different characteristics, were merged or separated and formed a new subcategory. At the last stage, the subcategories which seemed to have common characteristics were merged in the common or the main categories.
To measure the trustworthiness of the data, we used the four components of Credibility, transferability, dependability, and confirmability proposed by Lincoln and Guba (15).
Credibility was obtained through the examination of interview transcripts and clarification of ambiguities by co-researcher. Transferability was ensured by incorporating informed participants. Dependability was achieved when identical answers were given to the same questions by participants. Finally, to obtain confirmability, we tried to avoid any bias in the subject of research before and after the interviews so that the results of the research would also be approved by other readers (15,16).

Results
The participants were 20 transferred faculty or those who requested to be transferred, including 12 male and 8 female. Three of the participants had managerial positions. The interpretation of the data revealed many factors concerning the retention of faculty in medical schools. The findings of the qualitative content analysis on the retention of faculty were divided into 3 categories and 14 sub-categories. The results were shown in Table 1. The review of the participants' opinion revealed different results that could be a function of the different conditions of the departments or faculties of a medical school.
The first category was the retention enforcers, including 4 sub-categories of facilitated communication, distance, gaining experience, and support of authorities. Summary of the participants' views in these subcategories included facilitated interpersonal relationships, friendly working atmosphere, better cooperation, intimate communication, proximity to universities, greater opportunities for junior faculty to teach and promote, more salary, more efforts by authorities to solve problems and administrative bureaucracy. Our findings on retention enforcers included facilitating communication, authorities' support, proximity to major universities, gaining experience. In their study, Hendrickson et al. (2013) considered the satisfaction of faculty to be relevant to their role in fulfilling the mission of the university (17). It seems that the efforts of university authorities to create favorable human relationships and to focus on institutionalizing it in the university atmosphere will pave the way for the retention of faculty, which requires special attention of the officials. Dittmer (2017) showed that the university atmosphere and the satisfaction of working with colleagues affects the retention of faculty (18). Also, our results were consistent with Mirkamali et al. (2015) study on providing a secure environment to facilitate teamwork for the retention of employees (19). In this regard, the reduction of administrative bureaucracy, the efforts of authorities to solve the problems of faculty, and improving their quality of life are among the enforcers of the retention of faculty.
Johnson's study also showed that improving faculty's quality of life and providing a high level of job satisfaction improve the retention and promotion of faculty (20). Therefore, it is crucial to pay special attention to the needs and requests of faculty and to solve their problems. Another retention enforcer is providing the development programs and the job opportunities for the growth of faculty. It seems that the provision of individual Singapore were consistent with these finding (23) Retention strategies were another category in this study. As much as the recruitment of faculty is important for schools, the use of appropriate methods and strategies for the retention of faculty is crucial. To improve the retention of faculty of schools, authorities must provide faculty with the opportunity for growth through creating research opportunities and connecting with major universities. Murugappan and Durga (2015) suggested that providing career and research opportunity strongly affects the retention of faculty (24). This study has some limitations, the most important of which is persuading the transferred faculty to participate in the study. To this end, we attempted to emphasize the objective of the study on improving the situations of the faculty in schools and that their personal information would be treated strictly confidential. Another limitation is that the number of basic science faculty was higher than clinical science. Considering that Iran is a vast country with different cultural characteristics, further research is needed to explore the factors affecting the retention of faculty. Moreover, identifying these factors can help government making policies on the process of recruitment and retention of faculty.

Conclusion
The present study suggests that several factors contribute to the retention of faculty in medical schools. The role of the authorities' support in facilitating the retention of faculty is significant. They can establish an appropriate system for recruitment and promotion of faculty, support their academic activities, build a proper network with major universities, and provide individual development programs so that more faculty can attend educational programs at major universities. They should create a more positive environment to foster a sense of belonging among their human resources and reduce their intention to move to another university. The solutions presented in this study can affect the extended retention of faculty.

Declarations
List of abbreviations Not applicable.
Ethics approval and consent to participate: The study was approved by research ethics committee of Fasa University of Medical Sciences (Number of ethics code: IR.FUMS.REC.1398.044). The written consent was obtained from all the participants. After the purpose was stated and the methodology was described, written informed consent was obtained from all participants. In all research steps, confidentiality was observed and codes were used to refer to the participants for reporting the findings. Furthermore, the participants were ensured that they could withdraw from the Study at any time. The characteristics of the participants have been presented using code identifiers.

Consent for publication
Not applicable.

Availability of data and materials
The data that support the findings of this study are not publicly available, but can be obtained from the authors on reasonable request. All data are available from the corresponding author on reasonable request.