Faculty retention in regional medical schools in Iran: a qualitative content analysis

Background and purpose Recruitment and retention of competent faculty members are important in maintaining and improving the quality of education and research performance of universities. The aim of the present study was to find out the faculty members’ views, experiences, and attitudes to identify the reasons for faculty attrition and retention in regional medical schools in Iran. Methods In this qualitative study, we used a content analysis method. The participants included 12 faculty members who had been transferred to type I universities, four faculty members who had applied for transfer, four with more than 10 years of experience and working in the type 3 universities with no intention to be transferred. Data were collected using semi-structured interviews, which were conducted either face-to-face or via phone calls. The interview was developed for this study (Supplementary file). To measure the trustworthiness of the data, we evaluated four components of credibility, transferability, dependability, and conformability, as proposed by Lincoln and Guba. Results The findings were classified into three categories and 14 subcategories. The first category was “retention facilitators” including four subcategories of facilitated communication, proximity to major universities, gaining experience, and support by authorities. The second category was “retention threats” including six subcategories of social infrastructure, individual dimension, occupation dimension, economic dimension, sense of respect, and executive management. The third category was “retention strategies” which included four subcategories of recruitment and promotion processes, inter-university collaboration with type I universities, facilitation of the scientific growth, and fulfilment of the safety needs. Conclusion Several factors play a role in the faculty members’ retention in regional medical schools in Iran. Authorities can create a more positive environment by devising a suitable reward system, supporting academic activities, and increasing the level of faculty autonomy practically to develop a sense of belonging among them and reduce the intention to be transferred among their human resources. Supplementary Information The online version contains supplementary material available at 10.1186/s12909-020-02473-y.


Background
Faculty members, as the cornerstone of education in medical sciences [1], are considered an important asset for any higher education institution [2]. Ranking of universities in both national and international arenas is also dependent on the quality of the faculty member [3]. Recruitment and retention of talented faculty members are important in maintaining and improving the quality of education and research performance of the universities [4]. One of the challenges to which small medical schools are faced is recruitment of faculty members, which can impose a signi cant burden on both individuals and institutions due to its complexity and di culty [1]. An even more important challenge is the transfer or attrition of faculty members. According to a study conducted in the United States, ve out of ten faculty members are transferred over ten years [5]. In this regard, Fang and Bednash (2014) reported that 11.8% of full-time faculty members in 2010 left their full-time jobs by 2011 [6].
Concerns about the faculty retention usually stem from the fact that the transfer of the faculty imposes heavy costs on universities due to the loss of employment investment, recruitment of substitute faculty members, and the long processes of employment. Moreover, the negative impact of faculty substitution and early transfer can interrupt the education and counseling, with major consequences for the academic system [1,7]. On the other hand, the criteria for faculty retention are often vague, and there is no transparent mechanism for retaining faculty members in the universities [2].
Various studies have been conducted in higher education institutions to identify the factors affecting the faculty retention. In this regard, Soomro and Ahmad (2013) suggested some solutions in the eld of education, research, and community services to retain the faculty [2]. Breslow, on the other hand, showed that some faculty members moved due to personal reasons, unsupported working environments, and better offers elsewhere [8]. Lee (1982) found that faculty attrition for personal reasons, job dissatisfaction, and low salary was slightly higher at state universities, compared to social and technical sciences schools [9].
Structured programs seem to be effective in faculty development, and enhancement of the quality of student learning and progress can lead to faculty retention. Ries et al. (2012), in a study at the National Center of Leadership in Academic Medicine (NCLAM) of the University of California, found that programs, including professional development workshops, strategic planning, individualized academic performance counseling, mentoring with a senior faculty member for professional development, and network building with other faculty members for promoting assistant professors in health sciences had signi cant effects on the retention of newly employed assistant professors [1]. Locke also found that faculty members in different areas had different attitudinal and behavioral patterns shaped by their distinct epistemology, organizational commitment, and social relationships [10] and could be highly effective in faculty retention. Therefore, universities need to design and implement programs for the complex processes of faculty employment to maintain their human resources and reduce the negative consequences of faculty transfer.
In Iran, faculty members are employed in a competitive environment after their scienti c and general competencies are approved by relevant authorities. Faculty attrition and a shortage of quali ed faculty members in smaller universities is one of the main problems of medical schools in Iran. Despite international and national interests in faculty retention, few studies have been conducted on this subject at Iranian medical schools. Examination of effective methods in faculty retention plays an important role in improving the educational and research status. Therefore, it is crucial to study the factors affecting faculty retention and attrition. Considering the differences in attitudinal and behavioral patterns, which are in uenced by multiple cultural factors and are associated with different faculty views about intention to transfer, this study aimed to nd out the faculty members' views, experiences, and attitudes in order to identify the reasons for their attrition and retention.

Study population and design
The main purpose of 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 the individuals [11]. We conducted a qualitative content analysis and our aim was to understand the lived experiences of the subjects. Generally, content analysis is an approach, which provides new knowledge and insights into a particular phenomenon. It presents valid inferences from data and is suitable for examining the experiences and views of people towards the issue of interest [12].
In this qualitative study, purposive sampling was the main sampling approach [13]. The participants were carefully selected to obtain the richest information and reach data saturation. The subjects included 20 faculty members, members who had applied for transfer, and those with more than ten years of experience working in regional universities without any application for transfer despite their families living in large cities. We aimed to identify their experiences, tendencies, and views about the reasons for faculty retention and attrition.
For data collection, the participants listed above were rst identi ed and contacted for participation in the study. Next, explanations regarding the research and its goals were presented to the participants, and their consent to participate in the study was obtained. We then agreed about the appropriate time and place of the interviews. Out of 20 interviews, 16 were conducted face-to-face, and four via phone calls. At the beginning of the interviews, we asked for the participants' informed consent to record the interviews, and they were assured that their personal information would remain con dential.
The sampling process continued until theoretical saturation [12]. The interviews lasted for 45-60 minutes and started with the following general question: "What do you think is the reason for faculty attrition in medical schools?" The interviews continued with questions, such as "What are the factors affecting faculty retention in medical schools?" and "What are your suggested strategies for encouraging the faculty to remain at small schools?", and ended with follow-up questions. To analyze the data, we performed a qualitative content analysis with the inductive reasoning approach. To this end, the data were read repeatedly, and then semantic units were extracted. After summarizing the units, condensed semantic units were obtained, which were reduced to a limited number of words, but were semantically equivalent to the original semantic units.
Next, semantic units with similarities were converted into codes by labeling. At this stage, we used peerchecking to ensure the trustworthiness of data interpretations. The number of primary codes was 123, which was reduced to 90 after merging similar codes and removing identical ones. This step was revised several times based on the participants' views. In the next stage, after comparing the codes, they were divided into subcategories. The subcategories were constantly compared and reviewed, so that we could merge or separate some of them based on common or different characteristics and form a new subcategory. In the nal stage, subcategories, which seemed to have common characteristics, were merged in the common or main categories.
To measure the trustworthiness of data, we evaluated the four components of credibility, transferability, dependability, and con rmability, proposed by Lincoln and Guba [14]. Credibility was evaluated through member checking and prolonged engagement with the data. The transcripts of interviews and extracted codes were presented to some of the participants (n = 8), and they were asked to comment on the researchers' perceptions of their statements and correct any incongruencies. Transferability was established through maximum variation sampling, which provided thick descriptions and straightforward examples of data. Dependability was also established as the participants provided similar answers to the same questions. Finally, for con rmability, we tried to avoid any bias towards the data as the ndings were shaped by the respondents [14,15].

Results
The study population consisted of 20 faculty members, including 12 males and 8 females; three of them were executive manager. Also, 9 participants were from two schools, and 11 were from three universities. Interpretation of data revealed many factors concerning faculty retention in medical universities. The ndings were divided into three categories and 14 subcategories. The results are presented in Table 1. Review of the participants' views revealed some differences, which could be attributed to different conditions in departments or faculties of medical schools.
The rst category was "retention facilitators", including four subcategories of facilitated communication, proximity to larger (type I) universities (the de nition of university ranking is given at the end of the section), gaining experience, and support by authorities. Summary of the participants' views about these subcategories indicated facilitation of interpersonal relationships, work activities in a friendly atmosphere, increased cooperation, intimate communication, greater opportunities for junior faculty members to teach and get promotion, higher salaries, more efforts by authorities to solve the problems, and existence of administrative bureaucracy.
In subcategories of facilitated communication and gaining experience, the participants stated: "In type III universities, there is a more intimate atmosphere, and things are done more easily. The lower workload and convenient interactions with the university staff are the reasons for my retention." (Participant 4) "The education system was suitable for me. The living standards were excellent because we lived in the university campus; we could both live and work in the same place." (Participant 1) The second category was "retention threats" including six subcategories of social infrastructure, individual dimension, occupational dimension, economic dimension, sense of respect, and executive management. The main threats to faculty retention were social infrastructure and individual dimensions.
The social infrastructure refers to the underdevelopment or lack of adequate facilities, such as advanced training centers, recreational centers, and sports clubs in towns. Therefore, some faculty members needed to move away from their families and spend their weekends commuting between the family hometown and workplace, which increases their tendency to transfer to other universities.
Summary of the participants' views about these subcategories revealed the following results: lack of living and medical facilities in small cities; cultural differences among non-native faculty members; willingness of the faculty members to live with their families; lack of facilities in the faculty housing provided by universities; authorities' negligence of the faculty members' academic activities; dissatisfaction with increased administrative workload; poor performance of school o cials in retention and recruitment of faculty members; inadequate facilities for the children of faculty members in small cities; greater opportunities for academic activities in type I universities; and better nancial status of type I universities. In subcategories of social infrastructure, individual dimension, sense of respect, and executive management, some of the participants remarked: "What facilities have they provided for me to stay in the university? I regret having stayed there. Why shouldn't I go to another university for a couple of years?" (Participant 12) "The main reason I moved was my family." (Participant 10) "Some new technologies are available at type I universities." (Participant 6) "There is so much work to do that I do not even have the time to do my own work (education and research); for example, for retraining, I need to make sure that the workshop has been held." (Participant 16) The third category was "retention strategies" including four subcategories of recruitment and promotion processes, inter-university collaboration with type I universities, facilitation of scienti c growth, and provision of welfare issues. Summary of the participants' views about the processes of faculty employment and promotion indicated the need for recruiting local faculty members (living in remote areas), planning for faculty recruitment during PhD or other specialty courses based on their resume, establishing longer periods of commitment, having commitment to an extended period of retention, facilitating the process of faculty recruitment, and shortening the time to promotion.
In addition, summary of the participants' views in this area showed the following ndings: need for communication with the faculty members of type I universities; encouraging research teams with the aim of using the facilities of type I universities; providing opportunities for faculty members to experience working in type I universities; doctoral and postdoctoral fellowships; macro-planning for introducing further non-nancial incentives, such as educational workshops and sabbatical leaves; facilitating the promotion of staff; improving communication with industry; providing opportunities for education and research development; giving permission to clinical faculty members to perform their own academic activities; providing nancial and non-nancial incentives; increasing the salary of the faculty members; improving accommodation; providing job security; selection of committed school managers who would motivate the faculty members. In subcategories of facilitating scienti c growth, inter-university collaboration with type I universities and ful lling welfare needs, some participants stated: "Residents of other universities should be identi ed, their resume and CV should be reviewed, and they should be employed in the university." (Participant 3) "They can be more exible. A university, which offers a Master's or PhD course, has professors with eight to ten published articles. However, it is important for them to write proposals and collect data in type III universities. I think promotions should be facilitated in underprivileged regions." (Participant 4) "It is possible to sign contracts with type I universities and use their facilities." (Participant 17) "Since faculty members are allowed to establish knowledge enterprises, universities should support them." (Participant 2) "A manager should rst be able to manage himself/herself and be honest. Most managers are willing to be transferred to type I universities, so that they can have the opportunity for promotion. Managers should accept that their school is excellent and should be satis ed with it." (Participant 15)

Discussion
Our ndings as to the faculty retention in regional universities con rmed more extensive threatening factors of faculty retention than facilitating factors. Other nding was the need to pay attention to the use of incentives for faculty retention. In this section, we discuss the subcategories that were most emphasized by the participants.
Our ndings on retention facilitators included facilitated communication, support by authorities, proximity to type I universities, and gaining experience. Hendrickson et al. (2013) stated that the satisfaction of faculty members is relevant to their role in ful lling the goals of universities [16]. It seems that the efforts of university authorities to establish favorable human relationships and focus on their institutionalization in the university atmosphere can pave the way for faculty retention, which requires the special attention of the management. In this regard, Dittmer (2017) showed that the university atmosphere and satisfaction of working with colleagues can affect the faculty retention [17].
Our results are consistent with the ndings reported by Mirkamali et al. (2015) on providing a safe environment to facilitate teamwork for employee retention [18]. Reduction of administrative bureaucracy, authorities' efforts to solve the faculty members' problems, and improvement of their quality of life were among the factors in uencing the satisfaction and happiness of faculty members. Overall, welfare and educational facilities in small towns, the supportive atmosphere of small universities, and a positive attitude by the university management system can create a safe environment and a sense of security, which encourage the retention of the faculty members. Most participants believed that educational facilities and welfare can provide a supportive environment and develop a sense of security, which eliminates their concerns about the future.
A study by Johnson showed that improving the faculty members' quality of life and providing a high level of job satisfaction could improve the faculty retention and promotion [19]. Therefore, it is crucial to pay special attention to the needs and requests of faculty members and to solve their problems. Another retention facilitator is establishment of professional development programs and providing opportunities for the promotion of the faculty. It seems that establishment of individual development programs in line with the faculty's professional background can contribute to the retention of human resources in universities. Also, the use of educational programs of type I universities can improve individual development and faculty retention. A study by Ries et al. indicated that faculty retention was dependent on job satisfaction and academic progress [1].
Regarding the retention threats, absence of necessary social infrastructures, besides individual, occupational, and economic aspects of the workplace, was among the factors affecting the relocation or substitution of faculty members. Lack of suitable living facilities in cities eliminates the possibility of staying with family and encourages faculty relocation. The sense of belonging to a new environment is the basic need of every individual. Lack of a sense of belonging to the new environment is exacerbated by the absence of family and increases the faculty members' tendency to relocate. On the other hand, factors, such as work climate, favorable urban environment, living facilities, accessibility of recreational centers, and possibility of private activities enable faculty members to stay with their families, resulting in faculty retention.
In Iran, faculty members of basic and clinical sciences courses are considered full-time employees and are not allowed to have outside work activities unless they obtain permission from the university and the Ministry of Health. This includes private pro t-making activities outside the university (e.g. working in a personal o ce, pharmacy, laboratory, diagnostic center, educational center, charity organization, or private hospital). However, some faculty members do like the opportunity to have such private activities. We believe that by increasing the salary and bene ts of faculty members and providing job security, we can reduce their need to pursue private activities and facilitate faculty retention in small universities.
Since changes in the urban infrastructure do not solely depend on universities, it is crucial that university administrators pay special attention to the faculty members' cultural differences and desires while designing faculty recruitment policies and planning for recruiting local faculty members. Cultural convergence is one of the important issues that requires the authorities' attention when recruiting faculty members. Cultural difference in this context means that faculty members who are recruited to type II or III universities in towns feel a difference between their own lifestyle and the new community. These individuals are concerned about cultural rejection and the future of their families. Therefore, they are often forced to live apart from their families and commute weekly between their place of residence and employment, which can ultimately lead to faculty attrition.
In employment programs, it is advisable to consider the individual characteristics and desires of the applicants in all domains, including lifestyle, interests, and concerns. Furthermore, provision of good social welfare services at universities in remote cities is one of the issues that should be considered by university planners. In order to facilitate the economic growth of faculties (departments), it is important for universities to be involved in the industry and reduce the restrictions on personal activities in basic sciences (University-Industry Relations). Lord and Farrington (2006) also show that employees need to be ensured about a safe and secure environment for their families in order to remain in a job [20]. Moreover, Lindfelt et al. (2018) found that balance between work and life was effective in reducing the faculty members' intention to change their job [21]. Lack of a sense of respect by o cials was another issue threatening the faculty retention. In this regard, the results of a study by Horwitz et al. in Singapore are consistent with the present ndings [22].
Another category emerging in the present study was retention strategies. Considering the importance of faculty recruitment at schools, the use of appropriate methods and strategies for faculty retention is crucial. To improve faculty retention at schools, authorities must provide faculty members with opportunities for professional growth through promoting research activities and inter-university collaboration with type I universities. In type I universities, postgraduate students are usually residents, and professors can facilitate their own professional development through interactions with these students. However, conditions are not always as favourable in type II or III universities in underprivileged areas. The majority of participants believed that if they could participate in academic and research programs of type I universities at least two days a week, their professional development would be facilitated.
Murugappan and Durga (2015) suggest that career and research opportunities strongly affect the faculty retention [23]. Employment of local faculty members and facilitating their promotion can be also one of the ways to retain faculty members. Our ndings are consistent with the results reported by Nderitu (2014) regarding the impact of transparent policies on the recruitment, promotion, and retention of faculty members [24]. Also, the results of this study showed that longer commitments the could affect faculty retention. In this regard, Lavania et al. (2011) suggested exible policies and programs for faculty retention [25]. Besides, it is crucial to pay special attention to the individual, economic, and social needs of faculty members.
This study had some limitations. -Shortage of time of the research participants and breadth of the research community in three universities were the limitations in the collection of data. We used telephone interview to reduce these limitations.
Another limitation of this study was the higher number of basic sciences faculty members than clinical sciences faculty members. Since Iran is a vast country with different cultural characteristics, further research is needed to explore the factors affecting the faculty retention. Moreover, identi cation of these factors can help governmental policymakers in the process of faculty employment and retention.

Conclusion
According to the present ndings, several factors contribute to faculty retention in small medical universities located in small towns. The role of authorities' support in facilitating the faculty retention was signi cant. Authorities can establish an appropriate system for recruitment and promotion of faculty members, support their academic activities, build a proper collaborative network with type I universities, and design individual development plans, so that more faculty members can attend educational programs at type I universities. They should also create a more positive environment to foster a sense of belonging among human resources and reduce their intention to transfer. Overall, the solutions presented in this study can affect the extended retention of faculty members.