No full-text available
To read the full-text of this research,
you can request a copy directly from the authors.
Surveying the changing climate of Northern Territory medical workforce retention
Abstract
Introduction:
Low retention is a significant contributor to medical workforce shortages in rural and remote regions of Australia, including in the Northern Territory (NT). Many of these areas are susceptible to climate change, which could exacerbate workforce retention problems.
Objective:
To examine factors influencing medical workforce retention in the NT, including the potential impact of climate change.
Design:
Cross sectional online survey of NT medical professionals, distributed via email through professional networks. Predominantly quantitative mixed methods (descriptive statistics, multivariate logistic regression, thematic analysis). Main 2 outcome measures reported were proportion of respondents intending to leave the NT, timeframe of intention to leave and motivating factors.
Findings:
Of 1407 registered practising medical professionals in the NT, 362 responded who met inclusion criteria (26% estimated response rate) and 351 completed all questions. Of the latter, 143 (41%) intended to leave the NT, 102 (29%) were unsure, and 106 (30%) did not intend to leave. Among doctors in training (DITs) 67 (55%) intended to leave and 29 (24%) were unsure. The best multivariable predictive model included only practice type (with general practitioners/rural generalists and non-GP specialists significantly less likely to intend to leave compared to DITs), and location of primary medical degree (with non-NT training non-significantly associated with greater intention to leave). Of those intending to leave 94 (66%) reported planning to do so within two years. Training and career development opportunities, job dissatisfaction, moving to a preferred location and family-related factors were all important motivators. Of those considering leaving, 58 (24%) identified climate change as a motivating factor.
Conclusion:
Retention remains a key challenge in addressing rural workforce shortages. In addition to established factors, climate change is an important driver that has the potential to worsen workforce shortages in susceptible regions.
ResearchGate has not been able to resolve any citations for this publication.
Introduction:
Rural health services throughout the world face considerable challenges in the recruitment and retention of medical specialists. This research set out to describe the factors that contribute to specialist workforce retention and attrition in a health service in rural Tasmania, Australia.
Methods:
This qualitative study utilised in-depth interviews with 22 medical specialists: 12 currently employed by the service and 10 who had left or intended to leave. Interview transcripts were thematically analysed to identify professional, social and location factors influencing retention decision-making.
Results:
Professional and workplace factors were more important than social or location factors in retention decision-making. Tipping points were excessive workloads, particularly on-call work, difficult collegial relationships, conflict with management, offers of more appealing positions elsewhere, family pressure to live in a metropolitan area, educational opportunities for children and a lack of contract flexibility. Inequitable workload distribution and the absence of senior registrars contributed to burnout. Financial remuneration was not a primary factor in retention decision-making, however, there was acknowledgement of the need to ensure equitable pay scales, flexible employment contracts including statewide positions and increased CPD payments/leave. Specialists who had autonomy in determining their preferred work balance tended to stay, as did those who had family or developed social connections within the area, rural backgrounds and a preference for rural living.
Conclusion:
To improve specialist workforce retention, rural health services should ensure a professionally rewarding, harmonious work environment, without onerous out-of-hours demands and where specialists feel valued. Specialists should have autonomy over workloads, flexible contracts, appropriate financial remuneration and enhanced access to CPD. New specialists and their families should have additional support to assist with social integration.
Objective:
To describe characteristics and outcomes of women birthing within GP-obstetrician (rural generalist) supported rural (level 3) obstetric units in Queensland.
Design:
Retrospective descriptive study.
Setting:
21 GP-obstetrician supported birthing units in Queensland.
Participants:
Women (n = 3111) birthing from January 2017 to December 2017.
Main outcome measures:
Patient, pregnancy and labour characteristics and key maternal and neonatal outcomes routinely recorded in the Queensland Perinatal Data Collection and Queensland Hospital Admitted Patient Data Collection were compared to Queensland public hospital aggregate data.
Results:
Women birthing in rural maternity units were significantly more likely to be Aboriginal or Torrs Strait Islander (16% v 9%), < 20 years old (7% v 4%), term deliveries (96% v 91%), achieve spontaneous onset of labour (67% v 51%), and birth (71% v 60%) (p<0.001) compared with all Queensland public hospitals. They were significantly less likely to be nulliparous (36% v 40%), use pharmacological analgesia (65% v 69%), or have continuous electronic fetal monitoring in labour (54% v 66%) (p<0.001). Neonatal outcomes were comparable; with no significant difference in stillbirth rate between rural units and all Queensland public hospitals (4.8 v 7.3 per 1000 births). Precipitate delivery was the most common labour complication (36% v 33%) (p<0.001).
Conclusion:
GP-obstetrician (rural generalist) supported rural birthing units in Queensland provide important access for low and medium risk women to deliver locally, with strong indicators of quality and safety.
Background:
Residents of remote communities in Australia and other geographically large countries have comparatively poorer access to high-quality primary health care. To inform ongoing policy development and practice in relation to remote area health service delivery, particularly in remote Indigenous communities, this review synthesizes the key findings of (1) a comprehensive study of workforce turnover and retention in remote Northern Territory (NT) of Australia and (2) a narrative review of relevant international literature on remote and rural health workforce retention strategies. This synthesis provides a valuable summary of the current state of international knowledge about improving remote health workforce retention.
Main text:
Annual turnover rates of NT remote area nurses (148%) and Aboriginal health practitioners (80%) are very high and 12-month stability rates low (48% and 76%, respectively). In remote NT, use of agency nurses has increased substantially. Primary care costs are high and proportional to staff turnover and remoteness. Effectiveness of care decreases with higher turnover and use of short-term staff, such that higher staff turnover is always less cost-effective. If staff turnover in remote clinics were halved, the potential savings would be approximately A$32 million per annum. Staff turnover and retention were affected by management style and effectiveness, and employment of Indigenous staff. Review of the international literature reveals three broad themes: Targeted enrolment into training and appropriate education designed to produce a competent, accessible, acceptable and 'fit-for-purpose' workforce; addressing broader health system issues that ensure a safe and supportive work environment; and providing ongoing individual and family support. Key educational initiatives include prioritising remote origin and Indigenous students for university entry; maximising training in remote areas; contextualising curricula; providing financial, pedagogical and pastoral support; and ensuring clear, supported career pathways and continuing professional development. Health system initiatives include ensuring adequate funding; providing adequate infrastructure including fit-for-purpose clinics, housing, transport and information technology; offering flexible employment arrangements whilst ensuring a good 'fit' between individual staff and the community (especially with regard to cultural skills); optimising co-ordination and management of services that empower staff and create positive practice environments; and prioritising community participation and employment of locals. Individual and family supports include offering tailored financial incentives, psychological support and 'time out'.
Conclusion:
Optimal remote health workforce stability and preventing excessive 'avoidable' turnover mandates alignment of government and health authority policies with both health service requirements and individual health professional and community needs. Supportive underpinning policies include: Strong intersectoral collaboration between the health and education sectors to ensure a fit-for-purpose workforce;A funding policy which mandates the development and implementation of an equitable, needs-based formula for funding remote health services;Policies that facilitate transition to community control, prioritise Indigenous training and employment, and mandate a culturally safe work context; andAn employment policy which provides flexibility of employment conditions in order to be able to offer individually customised retention packages There is considerable extant evidence from around the world about effective retention strategies that contribute to slowing excessive remote health workforce turnover, resulting in significant cost savings and improved continuity of care. The immediate problem comprises an 'implementation gap' in translating empirical research evidence into actions designed to resolve existing problems. If we wish to ameliorate the very high turnover of staff in remote areas, in order to provide an equitable service to populations with arguably the highest health needs, we need political and executive commitment to get the policy settings right and ensure the coordinated implementation of multiple strategies, including better linking existing strategies and 'filling the gaps' where necessary.
Residents of rural and remote Australia have poorer health outcomes than their metropolitan counterparts. A major contributor to these health disparities is chronic and severe health workforce shortages outside of metropolitan areas—a global phenomenon. Despite emerging recognition of the important influence of place-based social processes on retention, much of the political attention and research is directed elsewhere. A structured scoping review was undertaken to describe the range of research addressing the influence of place-based social processes on turnover or retention of rural health professionals, to identify current gaps in the literature, and to formulate a guide for future rural health workforce retention research. A systematic search of the literature was performed. In total, 21 articles were included, and a thematic analysis was undertaken. The themes identified were (1) rural familiarity and/or interest, (2) social connection and place integration, (3) community participation and satisfaction, and (4) fulfillment of life aspirations. Findings suggest place-based social processes affect and influence the retention of rural health workforces. However, these processes are not well understood. Thus, research is urgently needed to build robust understandings of the social determinants of rural workforce retention. It is contended that future research needs to identify which place-based social processes are amenable to change.
As qualitative research becomes increasingly recognized and valued, it is imperative that it is conducted in a rigorous and methodical manner to yield meaningful and useful results. To be accepted as trustworthy, qualitative researchers must demonstrate that data analysis has been conducted in a precise, consistent, and exhaustive manner through recording, systematizing , and disclosing the methods of analysis with enough detail to enable the reader to determine whether the process is credible. Although there are numerous examples of how to conduct qualitative research, few sophisticated tools are available to researchers for conducting a rigorous and relevant thematic analysis. The purpose of this article is to guide researchers using thematic analysis as a research method. We offer personal insights and practical examples, while exploring issues of rigor and trustworthiness. The process of conducting a thematic analysis is illustrated through the presentation of an auditable decision trail, guiding interpreting and representing textual data. We detail our step-by-step approach to exploring the effectiveness of strategic clinical networks in Alberta, Canada, in our mixed methods case study. This article contributes a purposeful approach to thematic analysis in order to systematize and increase the traceability and verification of the analysis.
Background:
The geographical maldistribution of the health workforce is a persisting global issue linked to inequitable access to health services and poorer health outcomes for rural and remote populations. In the Northern Territory (NT), anecdotal reports suggest that the primary care workforce in remote Aboriginal communities is characterised by high turnover, low stability and high use of temporary staffing; however, there is a lack of reliable information to guide workforce policy improvements. This study quantifies current turnover and retention in remote NT communities and investigates correlations between turnover and retention metrics and health service/community characteristics.
Methods:
This study used the NT Department of Health 2013-2015 payroll and financial datasets for resident health workforce in 53 remote primary care clinics. Main outcome measures include annual turnover rates, annual stability rates, 12-month survival probabilities and median survival.
Results:
At any time point, the clinics had a median of 2.0 nurses, 0.6 Aboriginal health practitioners (AHPs), 2.2 other employees and 0.4 additional agency-employed nurses. Mean annual turnover rates for nurses and AHPs combined were extremely high, irrespective of whether turnover was defined as no longer working in any remote clinic (66%) or no longer working at a specific remote clinic (128%). Stability rates were low, and only 20% of nurses and AHPs remain working at a specific remote clinic 12 months after commencing. Half left within 4 months. Nurse and AHP turnover correlated with other workforce measures. However, there was little correlation between most workforce metrics and health service characteristics.
Conclusions:
NT Government-funded remote clinics are small, experience very high staff turnover and make considerable use of agency nurses. These staffing patterns, also found in remote settings elsewhere in Australia and globally, not only incur higher direct costs for service provision-and therefore may compromise long-term sustainability-but also are almost certainly contributing to sub-optimal continuity of care, compromised health outcomes and poorer levels of staff safety. To address these deficiencies, it is imperative that investments in implementing, adequately resourcing and evaluating staffing models which stabilise the remote primary care workforce occur as a matter of priority.
Background
Improved Primary Health Care (PHC) utilisation is central to reducing the unacceptable morbidity and mortality rates characterising populations living in remote communities. Despite poorer health, significant inequity characterises the funding of PHC services in Australia’s most remote areas. This pilot study sought to ascertain what funding is required to ensure equitable access to sustainable, high quality primary health care irrespective of geographical remoteness of communities.
Methods
High performing remote Primary Health Care (PHC) services were selected using improvement measures from the Australian Primary Care Collaboratives Program and validated by health experts. Eleven PHC services provided data relating to the types of services provided, level of service utilisation, human resources, operating and capital expenses. A further four services that provide visiting PHC to remote communities provided information on the level and cost of these services. Demographic data for service catchment areas (including estimated resident population, age, Indigenous status, English spoken at home and workforce participation) were obtained from the Australian Bureau of Statistics 2011 census. Formal statistical inference (p-values) were derived in the linear regression via the nonparametric bootstrap.
Results
A direct linear relationship was observed between the total cost of resident PHC services and population, while cost per capita decreased with increasing population. Services in smaller communities had a higher number of nursing staff per 1000 residents and provided more consultations per capita than those in larger communities. The number of days of visiting services received by a community each year also increased with population. A linear regression with bootstrapped statistical inference predicted a significant regression equation where the cost of resident services per annum is equal to 1698.83 x population) and the cost of resident and visiting services is equal to 2600.00 x population).
Conclusions
The research findings provide empirical evidence based on real costs to guide funding for remote PHC services that takes into account the safety and equity requirements for a minimum viable service. This method can be used as a transparent, coordinated approach to ensure the equitable delivery of sustainable, high quality PHC in remote communities. This will in turn contribute to improved health outcomes.
The purpose of this methodological article is to provide a primer for conducting a mixed analysis—the term used for analyzing data in mixed research. Broadly speaking, a mixed analysis involves using quantitative and quantitative data analysis techniques within the same study. In particular, a heuristic example using real data from a published study entitled "Perceptions of Barriers to Reading Empirical Literature: A Mixed Analysis" (Benge, Onwuegbuzie, Burgess, & Mallette, 2010) is used with the aid of screenshots to illustrate how a researcher can conduct a quantitative dominant mixed analysis, wherein the quantitative analysis component is given higher priority and qualitative data and analysis is incorporated to increase understanding of the underlying phenomenon.
The Northern Territory Medical Workforce Model (the medical model) projects the requirement for, and supply of, medical practitioners from 2006 to 2022. The medical model was produced as part of the Health Workforce Modelling Project established by the Strategic Workforce Committee of the Department of Health and Families (DHF) to inform workforce planning by projecting future numbers of health professionals in the Northern Territory (NT).
Objective:
To measure the time trends in retention of new rural doctors in Western Australia (WA) and identify factors associated with improved retention.
Design:
Retrospective inception cohort study of the 1154 doctors first commencing rural practice in WA in 2004-2013, who provided 1222 tours of service consisting of up to eight attachments at different rural practice settings.
Main outcome measure:
Failure of doctor retention as evidenced by an absence from the rural medical workforce of greater than 1 year and analysed using actuarial survival methods and Cox proportional hazards regression.
Results:
Comparing 2009-2013 with 2004-2008, there was an improvement of 10 percentage points in retention of new rural doctors at 2 years (58% versus 48% ) and 7 percentage points at 5 years (38% versus 31%). The retention failure rate ratio was 0.68 (95% CI, 0.58-0.83). The improvement at 5 years was largely attributable to gains in retention of those who began as GP registrars (37% versus 14%). Failure of doctor retention was lower in those who possessed procedural skills (RR 0.61, 95% CI, 0.47-0.78) and lower in international medical graduates than in those trained in Australia (RR 0.75, 95% CI, 0.59-0.95).
Conclusions:
New rural GP retention in WA has improved substantially, an observation at least consistent with government initiatives delivering a positive return. However, it remains the case that the majority of new doctors have left rural practice within 5 years of commencing their tour of service.
Poor retention of health workers is a significant problem in rural and remote areas, with negative consequences for both health services and patient care.
This review aimed to synthesise the available evidence regarding the effectiveness of retention strategies for health workers in rural and remote areas, with a focus on those studies relevant to Australia.
A systematic review method was adopted. Six program evaluation articles, eight review articles and one grey literature report were identified that met study inclusion/exclusion criteria.
While a wide range of retention strategies have been introduced in various settings to reduce unnecessary staff turnover and increase length of stay, few have been rigorously evaluated. Little evidence demonstrating the effectiveness of any specific strategy is currently available, with the possible exception of health worker obligation. Multiple factors influence length of employment, indicating that a flexible, multifaceted response to improving workforce retention is required.
This paper proposes a comprehensive rural and remote health workforce retention framework to address factors known to contribute to avoidable turnover. The six components of the framework relate to staffing, infrastructure, remuneration, workplace organisation, professional environment, and social, family and community support. In order to ensure their effectiveness, retention strategies should be rigorously evaluated using appropriate pre- and post-intervention comparisons.
Australian Health Practitioner Regulation Agency
- Medical Board
- Australia
Northern Territory in 2019: a very warm and dry year. Annual Climate Summary for Northern Territory.BOM;2020
- Bureau Of Meteorology
Review of Australian Government Health Workforce Programs
- Masonj
Mason J. Review of Australian Government Health Workforce
Programs. Australian Government Department of Health;
2013. [cited 2021 April 3]. https://www1.health.gov.au/inter
net/main/publi shing.nsf/Conte nt/revie w-austr alian -gover
nment -healt h-workf orce-programs
Health Workforce Modelling Northern Territory: Technical Report for the Medical Workforce Model.Northern Territory Department of Health and Families
- Guthridges Malyonr Zhaoy
The Northern Territory Allied Health Workforce Study
- Campbelln Smedtsa Lowes Keanes Smitht
Australian Institute of Health and Welfare Australian Burden of Disease Study: Impact and causes of illness and death in Australia
Australian Institute of Health and Welfare Australian Burden
of Disease Study: Impact and causes of illness and death in
Australia 2015 Summary Report. AIHW; 2019 (AIHW Cat.
no: BOD 21) [cited 2021 March 14]. https://www.aihw.gov.
au/getme dia/08eb5 dd0-a7c0-429a-b35f-c8275 e7a1d bf/aihwbod-21.pdf.aspx?inlin e=true
Australian Government Department of Health
Australian Government Department of Health. Medical
Workforce 2016 Factsheet. Commonwealth of Australia; 2018.
[cited 2021 April 3]. https://hwd.health.gov.au/resou rces/publi
catio ns/facts heet-mdcl-2016.pdf
The Northern Territory Allied Health Workforce Study
- N Campbell
- A Smedts
- S Lowe
- S Keane
- T Smith
Campbell N, Smedts A, Lowe S, Keane S, Smith T. The
Northern Territory Allied Health Workforce Study. Flinders
University. Flinders University, 2010. [cited 2021 April 3].
https://www.acade mia.edu/78241 37/The_North ern_Terri
tory_Allied_Health_Workf orce_Study_The_North ern_Terri
tory_Clini cal_School_and_the_Unive rsity_Depar tments_of_
Rural_Health_at?pls=RHCr9 pbNOZ
Australian Government Department of Health. Summary Statistics, Medical Profession
- Medical Board
- Australia
Medical Board of Australia. Registrant data: 01 July 2020 to
30 September 2020. Australian Health Practitioner Regulation
Agency; 2020. [cited 2021 February 1]. https://www.medic
alboa rd.gov.au/News/Stati stics.aspx
19. Australian Government Department of Health. Summary
Statistics, Medical Profession. Commonwealth of Australia;