IS AUSTRALIAN RURAL PRACTICE CHANGING? FINDINGS FROM THE NATIONAL RURAL GENERAL PRACTICE STUDY

ABSTRACT: The National Rural General Practice Study (NRGPS) was the first comprehensive national study covering rural and remote general practitioners throughout Australia. It was undertaken in 1996–1997 and drew on data from existing sources such as the Australian Bureau of Statistics and the Australian Institute of Health and Welfare, together with a postal survey of general practitioners in rural and remote areas. There was a 75% response rate to the survey, which covered professional issues, personal and social issues, personal background, patient issues, recruitment and retention programs and changing health services. Overall, the study findings confirmed those of previous individual State-based studies in the early 1990s and showed that there had been some changes since those previous studies. In particular, access to continuing medical education has improved, the rural medical workforce appears to be ageing, the proportion of women rural doctors is increasing and the projected length of stay in rural practice is decreasing. Whereas in the early 1990s the projection for rural doctor numbers was continuing decline, the NRGPS projected overall numbers in rural practice as staying approximately the same over the next 5 years. In the light of these trends, the challenge is to implement targeted initiatives that improve the recruitment and retention of rural and remote general practitioners.     

Systematic review of effective retention incentives for health workers in rural and remote areas: Towards evidence‐based policy

Background: Poor retention of health workers is a significant problem in rural and remote areas, with negative consequences for both health services and patient care. Objective: 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. Design: 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. Results: 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. Conclusions: 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.     

Work practices of rural and remote physiotherapists

ABSTRACT: Physiotherapists in rural and remote areas face challenges in their service delivery. The challenge is to provide accessible and comprehensive services to rural and remote Australians. Research was undertaken regarding the work practices of physiotherapists and the availability of other health professionals in rural and remote South Australia and Northern Territory. Rural and remote area physiotherapists in this study are likely to be sole practitioners with a gener-alist practice. The high number who have practising rights at public hospitals gives rise to service delivery with a wide range of clients and reduced opportunity for specialisation. In addition, the demand for physiotherapists to be multiskilled is increased with the lower number of resident medical specialists and allied health professionals in rural areas. Greater access to other professionals for rural and remote Australians may come from the development of resource networks supported by regional organisation of resources and infrastructure.     

Factors affecting the recruitment and retention of pharmacists to practice sites in rural and remote areas of New South Wales: a qualitative study

OBJECTIVE: To explore factors affecting recruitment and retention of pharmacists in rural/remote areas of New South Wales (NSW). DESIGN: Qualitative semistructured in-depth interviews. SETTING: Primary care--rural/remote community pharmacies. PARTICIPANTS: Purposive sample of 12 community pharmacists. MAIN OUTCOME MEASURES: Factors affecting recruitment and retention of pharmacists in rural/remote areas of NSW. RESULTS: Respondents reported a variety of personal and professional reasons for taking up rural practice, including previous rural experience and a preference for working in rural over metropolitan areas. The main factor affecting retention in rural areas was the high level of professional satisfaction and interprofessional rapport. Perceived reasons for the current under-supply of pharmacists to rural/remote areas of NSW included changing demographics of the pharmacy undergraduate degree programs and pharmacy workforce, and negative perceptions of rural pharmacy practice and rural lifestyle. CONCLUSIONS: This study identified factors believed to affect recruitment and retention of pharmacists in rural/remote areas. There appears to be considerable overlap between the factors, with different weightings of importance for different individuals. The lack of consensus for a proposed method of resolving this problem highlights its complexity and the need for further studies in this area.     

Short‐stay rural and remote placements in dental education,an effective model for rural exposure: A review of eight‐year experience in Western Australia

Objectives: The increase in demand for dental care over the next 10 years is expected to outstrip the supply of dental visits in Australia, resulting in an ongoing shortage of dental practitioners. As trends in medicine have shown, the greatest effect will be felt in rural and remote regions, where an undersupply of dentists already exists. It is clearly evident that it is important to provide strategies that will increase the recruitment and retention of practitioners in rural and remote areas. Previous research suggested an increased likelihood for health graduates to choose rural practice if they have a rural background, or were exposed to rural practice during their education. Short‐stay (three to four weeks) placements for final‐year dental students has been part of dental education in Western Australia for near on a decade. Methods: This paper reflects on the experiences gained from managing this placement program. Conclusions: Short‐stay placements are a quality learning initiative but need a high level of planning and a clear vision to be effective. Implications: The key factors in ensuring sustainable, student centred learning is driven through a small core group of staff who have strong direct links with rural and remote communities, students and support providers. The integration of service, education and research goals have played a critical role in sustaining placements. The philosophy underpinning the rural placements needs to be clearly articulated and applied effectively in each step of their implementation and a highly focused customer‐service driven implementation is required to make short‐stay rural and remote placements effective.     

Measuring rural allied health workforce turnover and retention: What are the patterns,determinants and costs?

Objectives: To measure variations in patterns of turnover and retention, determinants of turnover, and costs of recruitment of allied health professionals in rural areas. Design: Data were collected on health service characteristics, recruitment costs and de‐identified individual‐level employment entry and exit data for dietitians, occupational therapists, physiotherapists, podiatrists, psychologists, social workers and speech pathologists employed between 1 January 2004 and 31 December 2009. Setting: Health services providing allied health services within Western Victoria were stratified by geographical location and town size. Eighteen health services were sampled, 11 participated. Main outcome measures: Annual turnover rates, stability rates, median length of stay in current position, survival probabilities, turnover hazards and median costs of recruitment were calculated. Results: Analysis of commencement and exit data from 901 allied health professionals indicated that differences in crude workforce patterns according to geographical location emerge 12 to 24 months after commencement of employment, although the results were not statistically significant. Proportional hazards modelling indicated profession and employee age and grade upon commencement were significant determinants of turnover risk. Costs of replacing allied health workers are high. Conclusions: An opportunity for implementing comprehensive retention strategies exists in the first year of employment in rural and remote settings. Benchmarks to guide workforce retention strategies should take account of differences in patterns of allied health turnover and retention according to geographical location. Monitoring allied health workforce turnover and retention through analysis of routinely collected data to calculate selected indicators provides a stronger evidence base to underpin workforce planning by health services and regional authorities.     

Retention: An unresolved workforce issue affecting rural occupational therapy services

Failure to retain health professionals in rural areas contributes to the poor health status of these communities through an inability to deliver reliable and consistent services. Considerable attention has been focused on factors affecting recruitment of health professionals. Far less is known about factors affecting the retention of occupational therapists. This was the focus of this study. Ethnographic interviews were used to explore the experiences of 10 occupational therapists who had left rural practice. Six themes emerged from the participants' experiences, from when they first considered rural practice to reflections following their departure from it. These themes were initial appeal, facing the challenge, rural practice issues, the social sphere, reasons for leaving and the value of rural experience. These factors gave rise to a proposed Model of Retention Equilibrium, which suggests that retention can be improved by addressing the imbalance between incentives to leave and incentives to stay. The model provides a useful framework for occupational therapists contemplating rural practice, as well as for health services managers responsible for service delivery in rural areas.     

UNDERSTANDING RURAL AND REMOTE DIVISIONS UNDER A WORKFORCE FRAMEWORK

ABSTRACT: In Australia, divisions of general practice are the organisational structures for local networks of general practitioners. They facilitate communication across the profession and with other parts of the health system and are established in urban, rural and remote areas. Funding is provided contractually to divisions through the Federal Government's Divisions and Projects Grants Program. The under-supply of doctors and other health professionals in rural and remote areas of Australia is a serious problem that has far-reaching effects. The present paper argues that if the Divisions and Projects Grants Program is to be effective in achieving its aims and objectives, then the Program's policies must be responsive to the different needs, roles, constraints, expectations and capabilities of divisions and their members as well as the structural impediments imposed by the medical workforce.     

Dental visits in older Western Australians: a comparison of urban, rural and remote residents

OBJECTIVE: It has been reported that the aged in rural areas may not access regular dental care. The aim of this study was to describe dental visits for those 60 years of age and older living in urban, rural and remote locations in Western Australia and to determine factors associated with such visits. The main outcome was having had a dental visit in the previous 12 months. DESIGN: A cross-sectional telephone survey was conducted. SETTING: Urban, rural and remote locations in Western Australia. SUBJECTS: A total of 2100 participants, 60 years of age and older. RESULTS: The present study demonstrated that people in rural and remote areas of Western Australia had a longer time since their last dental visit than people in urban areas. Within each sex, age, country of birth, income, occupation and education group, the highest proportion of people having attended a dentist in the previous 12 months was in urban areas and the lowest was in remote areas. Controlling for sex, age, education and oral health status, compared to urban residents, rural residents were 14% less likely to have seen a dentist and remote residents were 27% less likely. CONCLUSION: The present study demonstrated that for the aged sector of the Western Australian population, geographical location is a major factor in the frequency of use of dental services and the reasons for dental visits. This raises concerns that improvement of oral health by prevention and early detection of tooth and gum problems is less likely to occur in rural and remote areas than in urban areas.     

Extending rural and remote medicine with a new type of health worker: physician assistants

The purpose of this paper was to demonstrate that the medical workforce shortage is an international phenomenon and to review one of the strategies developed in the USA in the late 1960s: the physician assistant model of health service provision. The authors consider whether this model could provide one strategy to help address the medical workforce shortage in Australia. A systematic review of the literature about medical workforce shortages, strategies used to address the medical workforce shortage, and the physician assistant role was undertaken. Literature used for the review covered the period 1967-2006. Physician assistants provide safe, high-quality and cost-effective primary care services under the direction of a doctor and respond to workforce shortages in rural and remote areas, family practice medicine and hospital settings. This model of health care provision has been adopted in several other developed countries, including England, Scotland, the Netherlands and Canada. The physician assistant concept might provide Australia with a novel strategy for addressing its medical workforce shortage, particularly in rural and remote settings.     

The ‘rural pipeline’ and retention of rural health professionals in Europe's northern peripheries

The major advance in informing rural workforce policy internationally over the past 25 years has been the recognition of the importance of the ‘rural pipeline’. The rural pipeline suggests that people with ‘rural origin’ (who spent some childhood years in rural areas) and/or ‘rural exposure’ (who do part of their professional training in rural areas) are more likely to select rural work locations. What is not known is whether the rural pipeline also increases the length of time professionals spend in rural practice throughout their careers. This paper analyses data from a survey of rural health professionals in six countries in the northern periphery of Europe in 2013 to examine the relationship between rural origin and rural exposure and the intention to remain in the current rural job or to preference rural jobs in future. Results are compared between countries, between different types of rural areas (based on accessibility to urban centres), different occupations and workers at different stages of their careers. The research concludes that overall the pipeline does impact on retention, and that both rural origin and rural exposure make a contribution. However, the relationship is not strong in all contexts, and health workforce policy should recognise that retention may in some cases be improved by recruiting beyond the pipeline.     

The oral health status and treatment needs of Indigenous adults in the Kimberley region of Western Australia

Objective: The oral health of Indigenous Australians, whether urban or rural, is significantly poorer than their non‐Indigenous counterparts, and it would be expected that the oral health of rural and remote Indigenous Australians would be particularly poor, although the extent of this extra disadvantage has not been thoroughly documented. The aim of this study was to assess the oral health status and oral health needs in a sample of adult residents of selected towns and remote communities in the Kimberley region of North‐west Australia. Design: A cross‐sectional survey (dental examinations and oral health questionnaires) was carried out. Setting: Rural and remote communities in the Kimberley region of Western Australia. Participants: Adults in four selected communities. Results: The mean Decayed, Missing and Filled Teeth (DMFT) score for all participants was 9.8 (SD 8.3). The mean DMFT increased with increasing age. Only 7.3% of people were caries‐free. A total of 13% of participants had periodontal pockets of 6 mm or more, and only 3% had no periodontal disease. More than a third (37%) of all participants had advanced periodontal disease. Only 21% of participants did not need any dental treatment. Conclusions: The oral health of Aboriginal and Torres Strait Islander people are listed as one of the priority areas of Australia's National Oral Health Plan. Based on the above results, oral health is clearly an important priority in the Kimberley.     

Supporting an emerging workforce: characteristics of rural and remote therapy assistants in Western Australia

OBJECTIVE: Multidisciplinary therapy assistants (TAs) are an emerging but poorly understood rural and remote allied health workforce. As an aid to planning and support of TA programs in rural and remote Western Australia (WA), the number, locality and a range of practice variables of rural and remote TAs in WA were determined. DESIGN: Survey questionnaire. SETTING: Rural and remote regions of WA. PARTICIPANTS: Allied health professionals, TAs, TA coordinators and managers of allied health in country regions of WA. MAIN OUTCOME MEASURES: Information was gathered on TA location, qualifications, employing organisation, allied health disciplines TAs work with, supervision practices, role and work scenarios. RESULTS: Ninety-eight TAs were identified in rural and remote WA with a further 23 vacant TA positions. Most TAs work across multiple allied health disciplines, half are located at a distance to their supervisors, and very few have a recognised qualification for their TA work. CONCLUSION: A substantial rural and remote TA workforce was found. A range of TA characteristics were identified that have considerable relevance to the future planning of TA initiatives in rural and remote WA.     

RURAL AND REMOTE ALLIED HEALTH PROFESSIONALS: IS DISTANCE EDUCATION A VIABLE OPTION FOR POSTGRADUATE STUDY?

ABSTRACT: The community expectations and professional needs of rural and remote area allied health professionals differ from their city counterparts. For example, career opportunities within the rural and remote area service are limited as is access to continuing education and peer group support. In addition, their role is more diverse than that of their city counterparts as they are called upon to provide expert knowledge over a wider range of areas.
Community expectations of rural and remote area allied health professionals has led to differences in educational needs. Clearly continuing education needs to be broadly based across specialisations and delivered in ways that allow access and are supportive of the circumstances of rural and remote area service workers.
This paper aims to introduce research about the professional educational needs of rural and remote area physiotherapists in South Australia and the Northern Territory. In a response to these needs a trial and evaluation of two postgraduate distance education subjects in relation to their suitability in meeting these needs is discussed. Finally, a Graduate Certificate in Physiotherapy (Rural and Remote Area Studies) will be presented as one possible solution to these dilemmas.     

MEDICAL SPECIALISTS SERVICING THE NEW ENGLAND HEALTH AREA OF NEW SOUTH WALES

ABSTRACT: There is increasing emphasis on research, policy and program activity to recruit and retain rural general practitioners in Australia. In contrast, until recently, there has been less attention paid to specific policies and programs relating to rural medical specialists. The New England Area Health Service experiences a shortage of general practitioners and specialists. This study surveyed this region's specialist workforce in 1998 and aimed to identify recruitment and retention issues affecting specialist rural workforce planning in north-west New South Wales. All 91 medical specialists practising in this rural area were surveyed. Seventy-one completed survey forms were received, representing a response rate of 78%. Positive features of rural specialist practice included the rural lifestyle, professional autonomy and available medical infrastructure. Negative features included professional isolation, long working hours, lack of locum relief and inadequate remuneration. Almost all surveyed specialists believe that there is a shortage of specialists servicing the New England Health Area. The major deficits in specialty areas identified relate to: dermatology; ear, nose and throat; obstetrics and gynaecology; orthopaedics; paediatrics; and urology. Recruiting and retaining medical specialists would be facilitated by improvements in the following areas: specialist resources and facilities, specialist locum scheme, remuneration and professional support. Effective strategies need to take account of local circumstances and be based on discussions involving all local key stakeholders.     

An innovation in Australian dental education: rural, remote and Indigenous pre-graduation placements

Anticipating the looming crisis in access to dental services in rural and remote areas, the Western Australian Centre for Rural and Remote Oral Health developed an undergraduate rural placement program to provide dental students of The University of Western Australia opportunities for direct experience of rural and remote practice during the final year of the undergraduate curriculum. The Rural, Remote and Indigenous Placement program started in 2002 and, to the end of 2005, had placed 78 final year dental students in supervised clinical practice in rural, remote or Indigenous practice. In this study, the evolution of the program (2002-2005) is described and student evaluation of the program is reported. While involved in the rural placement program, students were assessed by experienced dental practitioners and provided program evaluation. This structured feedback allowed continuous improvement of the program. Data from each year's graduates was also analysed to examine the question of influence of placements on practice location during the first 6 months after graduation. Although it will be many years before the effects of outplacement programs can be specifically attained, the evidence to date indicates that the program may be a valuable tool among the plethora of strategies being investigated to augment Australia's rural oral health workforce.     

Perceptions of occupational therapists practising in rural Australia: A graduate perspective

Background:  The difficulty in recruiting and retaining health professionals into rural and remote areas of Australia is well recognised. This study explored the perceptions of occupational therapists practising in rural locations regarding the essential skills necessary for rural practice and the ability of undergraduate education to prepare them for rural practice.
Methods:  A qualitative study using a phenomenological approach was conducted using semistructured in-depth interviews. Participants included occupational therapists who were graduates of James Cook University, who were practising in rural areas in Queensland and Victoria, and academic staff.
Results:  This study demonstrates that it is important for universities to develop both a mindset in their graduates for rural practice, as well as developing broader skills in addition to core discipline-specific skills. While subjects developing core occupational therapy skills are at the centre of undergraduate education, the importance of developing a broader understanding of rural health issues and skills in public health, primary health care and health promotion was emphasised.
Conclusion:  The development of specific skills to become competent rural practitioners and to cope with the challenges of rural practice can be strengthened through initiatives at the undergraduate level. Ongoing commitment from all universities across Australia to include rural curriculum content has the potential to improve recruitment and retention of occupational therapists and other health professionals into rural Australia.     

GETTING THE BALANCE RIGHT? GPS WHO CHOSE TO STAY IN RURAL PRACTICE

Background: Despite major challenges to the retention of rural GPs in Australia, little is known about why some rural GPs stay long‐term within their communities. Method: A group of rural GPs interviewed as part of another study about 10 years ago were re‐interviewed to explore their attitudes to their reasons for staying. Results: Eighteen of the original group of 23 could be contacted and 13 were interviewed. Factors that appeared to promote staying in rural practice were: strong attachment to the community; and practice arrangements that allow for adequate time off‐call and for holidays. However, several GPs were stressed and some had considered leaving. The stressors were similar to those identified in earlier research, including overwork and having to send children to boarding school. Conclusion: Personal and professional support arrangements within the community appear to be associated with decisions by rural GPs to remain in practice for substantial periods of time. Retention strategies should focus on facilitation of local integration. What is already known: Some doctors stay for prolonged periods of time in rural practice, although most leave after a few months or years. The reasons why rural doctors stay have until now not been explored. What this study adds: Rural doctors who stay for prolonged periods of time, defined in this study as 10 or more years, have established personal and professional support networks that have provided protection from the more negative aspects of rural professional life.     

Medical students and rural general practitioners: congruent views on the reality of recruitment into rural medicine

OBJECTIVE: In-depth exploration of the perceptions, experiences and expectations of current long-term rural GPs and medical students intent on a rural career, regarding the current and future state of rural medicine. DESIGN: Qualitative study using semistructured interviews. SETTING: Rural and remote towns in Central and Southern Queensland and the School of Medicine, University of Queensland. PARTICIPANTS: Thirteen rural GPs with 10-40 years experience. Medical students (five second- and seven third-year), all of whom are members of a rural students' club and have an intention to pursue rural practice. Interviews were conducted between August and December 2004. MAIN OUTCOME MEASURES: Emergent themes relating to participant perceptions of the current and future state of rural medicine. RESULTS: Despite large differences in generation and experience, medical students and rural GPs hold similar perceptions and expectations regarding the current and future state of rural practice. In particular, they cite a lack of professional support at the systems level. This includes specific support for: continuing medical education to obtain and retain the skills necessary for rural practice; dealing with the higher risks associated with procedural work; and consequences of medico-legal issues and workforce shortage issues such as long hours and availability of locums. CONCLUSIONS: Issues relating to recruitment and retention of the rural health workforce are identified by both cohorts as relating to professional support. Medical schools and institutional support systems need to join forces and work together to make rural practice a viable career in medicine.