4.1. Review of Findings
The emergent themes depict contextual challenges within all of the WoP-RIF domains, most of which negatively impact the attraction, recruitment and retention of AH staff. In both rural public sector health services, AH turnover and workforce shortages were a significant and chronic problem. The AH managers and executive commonly demonstrated a nuanced understanding of the recruitment and retention challenges in terms of the differences between AH disciplines, experience levels, life stage and social factors. However, despite the extent of the problem and a sound understanding the workforce challenges, there were few specific attraction, recruitment and retention strategies in place for the AH workforce. Notable exceptions are the financial and accommodation incentives offered by the rural health service to new health staff needing to relocate in response to the local housing shortage and the identified disincentive of costs associated with relocation.
This study also identified many examples in both services of poor processes, inefficiencies and inconsistencies in the application of policies and procedures which negatively impacted on the job satisfaction of AH staff. The importance of skilled AH leaders/managers was strongly supported and found to be commonly lacking in the two services. Managers in both services generally had a sound understanding of the significant challenges facing entry-level AH staff and the importance of PD for AH staff. Programs specifically targeting entry-level AH staff and supports for undertaking external PD for all AH staff were in place. However, because of organisational inefficiencies, these were not always accessible to all AH staff. The need for local AH career development opportunities was widely accepted as being essential for medium–long-term retention but very little activity was being undertaken to address this issue. This study highlighted how place-based social processes are an important influencing factor on job retention and this was generally well understood by AH management and executive, but again, very little activity was being undertaken to address the issue and none at all involving the broader community.
Overall, this study highlighted that public sector rural health services were not adequately addressing AH workforce challenges in an efficient, systematic or strategic manner and there was an urgent need for this occur to stabilise the existing workforce and support the development of a sustainable AH workforce. While this finding was not surprising to either the author or the two partnering health services, what was unexpected was the extent to which the challenges were so similar and that the bulk of the recommendations would be the same for both services.
The findings resonate strongly with other Australian AH rural workforce studies exploring the enablers and barriers to rural recruitment and/or retention [7
]. Of particular interest are the many similarities this study has with the findings in a recent qualitative study investigating AHPs’ transition to practice in rural regions of South Australia involving AHPs (n = 16) and managers/employers in the public sector (n = 2) and the private sector (n = 4) [19
]. Kumar et al.’s study categorised transition into ‘before’, ‘during’ and ‘after’ stages. In the ‘before’ stage, comparable findings relate to ‘job availability’, with AHPs discussing the need to ‘get experience’ and the difficulties in getting a job as a new graduate, and managers/employers discussing lengthy recruiting processes outside their locus of control (related to higher organisational departments) negatively impacting recruitment [19
]. In the ‘during’ stage, an analogous finding was the nature of rural practice (e.g., staffing shortages, small AH teams, lack of experienced staff) and the related challenges of providing mentoring/clinical supervision and accessing PD given the workplace environment. The challenges of rural practice environment were identified by both AHPs and managers/employers as contributing to almost all the AHPs feeling a lack of support in transitioning to the job. This was also found in the present study and has generally been well identified in the extant rural health workforce research [10
]. In Kumar et al.’s study, working in a supportive team was found to be an important aspect of supporting transition and deciding to stay and again this was well supported in this study and other AHP rural retention literature [19
]. The Kumar et al. study, as well as others, identified that incentives such as accommodation support may help attract AHPs to ‘go rural’ but these are not as important as access to PD and do not influence retention [18
]. In the Kumar et al. study, ‘social/lifestyle’ was a critical factor identified by employers/managers for successful transition and retention of AHPs. This involved different factors in the stages of transition including ‘before’ (recruiting)—the need to assess AHPs personality types and the likelihood of ‘fitting in’; ‘during’—the significance that social networks in the workplace play in social inclusion; and ‘after’(retention)—the need for AHPs to be embedded within the community with established connections with local people and groups [19
The critical role social/lifestyle factors play in successful transition and in supporting retention of AHPs in rural positions is increasingly being recognised in the extant literature (including by this author) and understanding is rapidly developing as to what processes are at play and which are modifiable [7
]. Kumar’s findings relating to social/lifestyle dimensions to retention are equivalent to the WoP-RIF community/place domain. This domain was recently explored in Cuesta-Briand et al.’s Western Australian study of factors influencing junior doctors’ (n = 21) career decision making [32
]. In their study, two key themes were identified: the importance of place and people, and broader context factors. Place and people factors resonate strongly with the present study’s findings involving the community/place domain. In regard to ‘place’, junior doctors with a strong rural intention discussed lifestyle factors associated with a particular place, and the importance of this place providing a sense of community. Respondents in this study also considered place to include the workplace and the need for colleagues to be friendly and supportive [32
]. In regard to ‘people’, the physical settings (both town and workplace) were identified as being intrinsically linked to the people inhabiting them and connectedness was important [32
]. Accommodating life partners’ careers was perceived as a main barrier to attracting and retaining doctors in rural places [32
]. This was upheld in the present study. While the place and people processes were congruent with this study’s findings, the broader context factors were dissimilar. Concerning the junior doctors’ thoughts regarding career opportunities, a commonly held viewpoint was that they were limited to primary care and general practice in rural places and that other medical specialisations would require them to train in an urban setting [32
Humphreys, Wakerman and Wells argue that a sustainable rural health system requires a sustainable ‘fit-for-purpose’ health workforce [33
]. To achieve this, policies that support an integrated training pipeline for all the health professions as well as an ‘effective, flexible, bundled retention strategy’ [34
] are needed. The author argues that the latter is always contextual and a redistribution of Australia’s health funding is needed at both national and state levels to allow health services and communities to implement strategies that can respond to the particular local challenges and opportunities affecting the recruitment and retention of health staff. Rigorous evaluation of these local endeavours may assist in identifying successful initiatives that have potential to be scaled up and contribute to the evidence-base for other health services and communities to use, as well as generally strengthen Australia’s rural health system [34
]. The next part of this research study is an evaluation involving analyses of the recommendations’ utility for improving AH retention by two Victorian rural public health services. The outcomes and conclusions drawn from this stage of the research are forthcoming.
4.2. Analysis of Recommendations
To analyse the 10 recommendations (listed in Table 4
), this study draws on two key studies presenting evidence-based recommendations to improve attraction, recruitment and retention of rural and remote workers: the World Health Organisation (WHO) [35
] and Buykx et al. (2010) [36
]. The analysis also draws on other rural health workforce literature where relevant.
4.2.1. Organisational/Workplace Domain
A key challenge identified as impacting the attraction of AHPs related to housing concerns and financial costs of relocating. In line with various WHO and Buykx et al. recommendations, the author recommended that transitional accommodation and reimbursement of relocation costs be routinely offered to AHP candidates needing to relocate for work (Recommendation 1).
Other Australian rural workforce studies have argued that ‘work systems’ need to suit the particular work environment and that local managers need to be able to develop employment policies that are responsive to the local context [3
]. To improve the attraction for AHPs who are the ‘right person’ for the work and place context, this study identified the need to strengthen existing recruitment materials by better promoting the work benefits and local lifestyle and living features, which is in line with Buykx et al.’s recommendation to maintain adequate and stable staffing (Recommendation 2).
The WHO identified that workplaces needed to meet an ‘acceptable standard’ and Buykx et al. recognised the importance of health services being perceived as ‘efficient’ organisations and that health workers’ initial entrée to the service can influence their perception about the suitability of the job and retention. Thus, streamlining the HR processes was recommended (Recommendation 3).
In a study of Australian remote health services, line managers were seen by health staff as representing the ‘organisation’ and their level of support was equated with what the organisation provides [22
]. Therefore, the need to support strategic and effective AH leadership was recommended (Recommendation 4).
4.2.2. Role/Career Domain
Entry-level AHPs were found to experience a difficult transition to work and those in early adulthood (early–mid 20s) who had relocated for work were found to be the most vulnerable to experiencing social disconnection and loneliness [17
]. Therefore, a support program to assist entry-level AHPs to adjust to work, build their clinical confidence, support their professional and career development, and foster social connection was recommended (Recommendation 5).
The importance of health workers’ professional identity for their job satisfaction and thus retention is widely recognised and both the WHO and Buykx et al. recommend professional development. For those AHPs working in rural and remote health services, given their more limited staff numbers, having regular access to profession-specific PD is particularly important for reducing professional isolation. Therefore, the author recommended reviewing the service’s AH PD policy to ensure equity of access for staff (Recommendation 6).
Both the WHO and Buykx et al. identified the importance of career advancement for retention. Development of an AH career pathways program was recommended (Recommendation 7).
4.2.3. Place/Community Domain
The importance of place and community were identified and addressed in recommendations 8 and 9. Buykx et al. identified the need for social and community support for new staff and their family members, while the WHO identified that living conditions had a significant influence on both rural attraction and retention and this included housing, employment opportunities for partners, adequate schools, road access and internet connectivity. Other AH rural workforce studies have identified the need for rural health staff to have meaningful social connections in place for medium–long-term retention [18
]. In WoP-RIF, these social and community factors were included under the community and place domain. Key elements included 1) having strategies in the workplace and in-community to welcome and support the initial adjustment of new staff and any family members, 2) local town residents being welcoming and accepting of newcomers, and 3) the active involvement of local community organisations to run activities/events that support the social integration of newcomers [14
4.3. Broader Relevance of the Recommendations
This study’s recommendations relating to the community/place domain will likely have generalisability for the broad health workforce in other high-income countries, especially those that have similar Westernised health, education, social and training systems, such as Canada, United Kingdom and United States. This is supported by research conducted in high-income countries across different rural contexts and health professions where matters relating to people and place (including supportive work environments) are often identified as being of high importance in attracting and retaining health professionals [30
]. Further exploration is needed as to whether these community/place recommendations could have relevance for rural-based health professionals from low-income countries given the differences in cultures and health and education systems [41
]. On the other hand, the recommendations made relating to organisational/workplace and role/career domains are likely highly contextual and relate specifically to Australia’s AHPs working in public sector services. In this circumstance, salaries and work conditions are collectively set under an EBA and did not feature as impacting either recruitment or retention. In the case of rural medical professionals (i.e., general practitioners) in high-income countries, most work in private practice and their earning potential is variable. For this group, income and work conditions are major factors for attraction and retention [38
]. In addition, recruitment of rural doctors may be influenced by financial enticements such as bonded placements, loan repayment schemes or other financial incentives, and these types of financial benefits are less commonly on offer to AHPs and nurses [41
The author supports the WHO’s position that a sustainable rural health workforce requires incentives and interventions that are attractive to individual health professionals [43
]. This requires that health professionals’ ‘reality’ is well understood, including the education and health systems and workplaces in which they are trained and/or work [43
]. Thus, in the case of organisation/workplace and role/career domains, these ‘realities’ will likely markedly differ between health professional groups (allied health, medicine, nursing). In addition to needing to address the differing realities between the health professions, effective incentives and interventions must also be able to flexibly respond to the fact that the three domains are interlinked and career aspirations and quality of life needs will change over the life course.