Remote health workforce turnover and retention: what are the policy and practice priorities?

Abstract

BackgroundResidents 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 textAnnual 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’.ConclusionOptimal 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 collaborat...

The Whole-of-Person Retention Improvement Framework: A Guide for Addressing Health Workforce Challenges in the Rural Context

“…In Onnis' study, access to suitable affordable accommodation, safe work conditions and regular leave were identified as being important work conditions for remote contexts [4]. Various 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 [3,4].…”

“…High staff turnover and long-term unfilled positions limit the health services that can be provided. This simultaneously results in heavy workloads for existing staff, which negatively impacts upon their job satisfaction, leading to further staff turnover [3,4]. Given their large land masses and small, broadly-dispersed populations with high proportions of Indigenous peoples, high income countries like Australia and Canada face additional challenges meeting their rural populations' health needs.…”

“…Given their large land masses and small, broadly-dispersed populations with high proportions of Indigenous peoples, high income countries like Australia and Canada face additional challenges meeting their rural populations' health needs. In Australia, approximately seven million people (28% of the population) live in rural and remote areas, and health workforce shortages have been strongly attributed to unaddressed healthcare needs [1,3,5,6]. In an attempt to address these rural workforce challenges, the Australian government has been implementing a range of policy measures for more than twenty years.…”

The importance of organizational commitment in rural nurses' intent to leave

“…'s (1993) three components of organizational commitment: affective commitment, continuance commitment, and normative commitment, the components of affective commitment (commitment associated with a sense of belonging and emotional attachment) and normative commitment (commitment associated with a sense of duty or obligation) are particularly important in rural settings where personal and professional lives are intertwined and the healthcare facility is often a major part of the community. In small rural and remote communities, where work teams can be very small with frequent gaps in staffing (Wakerman et al., 2019), team dynamics, everyday practice experiences, and locally available workplace and community supports may strongly influence RNs/NPs' and LPNs' organizational commitment. In rural and remote settings, work systems need to suit the realities of local contexts to be perceived as working well and being supportive (Cosgrave, 2020).…”

A community-based co-designed genetic health service model for Aboriginal Australians

“…By employing a local Aboriginal workforce, MJDF negates these identified workforce deficits as MJDF community workers are already living in these areas and are innately familiar with cultural aspects that may limit service engagement. Building increased capacity of local Aboriginal workers is essential in remote areas where limited housing, facilities and peripheral services make it problematic for mainstream services to employ permanent staff [ 48 ]. This is particularly true for rare genetic disorders with intermittent distribution of potential clients across large geographic areas.…”