Securing and retaining a mental health workforce in Far Western New South Wales

OBJECTIVE: To identify strategies local managers can use to optimise recruitment and retention of mental health staff in rural locations. DESIGN: Forty-one staff were interviewed about factors that attracted them to work in remote locations, their initial intentions and factors that encourage them to stay. SETTING: The former Far West Health Area of New South Wales. RESULTS: Overall job satisfaction was high (68%). Key attractors were rural lifestyle and environment. Family reasons, the field of work and the rural lifestyle were factors that keep staff in their positions. Some mentioned the desire to achieve professional goals and see projects completed. Many staff reported that their initial intentions to stay had remained the same (43.9%). Reasons for extended intention to stay were: greater career opportunities; a desire to complete professional goals; extension of positions; and personal factors. The most common reason for leaving was better career opportunities. Other reasons included: changes to personal commitments; heavy workloads or burnout; service management; and workplace politics. A large number of respondents mentioned key differences when comparing rural and metropolitan areas: more travel (greater distances); less service options for referral; greater spectrum of illnesses and conditions; more autonomy and responsibility. CONCLUSIONS: Strategies to recruit and retain staff must take account of personal needs and aspirations. While there is room for state strategies to improve employment incentives, there is also considerable scope for local managers to improve the design and attractiveness of jobs.     

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.     

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.     

Implementation of diabetes prevention programs in rural areas: Montana and south-eastern Australia compared

Objective: To identify the key elements that enabled the Greater Green Triangle Diabetes Prevention Project (GGT DPP) and the Montana Cardiovascular Disease and Diabetes Prevention (CDDP) programs successful establishment and implementation in rural areas, as well as identifying specific challenges or barriers for implementation in rural communities. Methods: Focus groups were held with the facilitators who delivered the GGT DPP in Australia and the Montana CDDP programs in the USA. Interview questions covered the facilitators' experiences with recruitment, establishing the program, the components and influence of rurality on the program, barriers and challenges to delivering the program, attributes of successful participants, and the influence of community resources and partnerships on the programs. Results: Four main themes emerged from the focus groups: establishing and implementing the diabetes prevention program in the community; strategies for recruitment and retention of participants; what works in lifestyle intervention programs; and rural‐centred issues. Conclusions: The results from this study have assisted in determining the factors that contribute to developing, establishing and implementing successful diabetes prevention programs in two rural areas. Recommendations to increase the likelihood of success of programs in rural communities include: securing funding early for the program; establishing support from community leaders and developing positive relationships with health care providers; creating a professional team with passion for the program; encouraging participants to celebrate their small and big successes; and developing procedures for providing post‐intervention support to help participants maintain their success.     

Helping and hindering: perceptions of enablers and barriers to collaboration within a rural South Australian mental health network

Objective: To evaluate clinicians’ perceptions of what helps and hinders the delivery of mental health care across a service network in a rural setting. Design: Qualitative, semistructured interviews were conducted with 10 individuals who work in one rural mental health care service network. Setting: A regional centre in rural South Australia involving representatives of the mental health team, general practice, hospital, community health and nongovernment organisations. Results: Clinicians’ perceptions of barriers and enablers to working within their mental health care network were explored. Participants showed a strong shared commitment to effective mental health care delivery and a good understanding of the services that each offers. Interview data suggested that working relationships between local services could be perceived as stronger when a personal or historical element is recognisable. Similarly, the notion of familiarity and community involvement were perceived as facilitators in this network. A perceived barrier for participants was the failure to attract staff with mental health experience, leading to dependence upon the dedication and commitment of existing service providers. Conclusions: Collaboration is especially necessary in rural areas, where access to health care services is known to be difficult. The informality of relationships between service providers was shown to be the main facilitator in the network. This is both a strength as it promotes the communication between services and service providers that is essential for successful collaboration, yet is also a threat to the sustainability of the network based on the difficulties of staff recruitment and retention to rural settings.     

Expanding the role of paramedics in northern Queensland: An evaluation of population health training

Objective: To describe the experience of the paramedics doing the population health component of the Graduate Certificate in Rural and Remote Paramedic Practice. Design: Analysis of paramedics' reported opinions about the course and its impact. Setting: Primary care. Participants: Data were obtained from de‐identified surveys submitted by the paramedics at the beginning and the end of the population health component of the course. Results: All paramedics felt that after the course they were more committed to undertaking population health activities in their work and were better prepared to do so. As a result of undertaking the course, 73% of students have already changed their practice. Seventy‐five per cent agreed that doing the course would increase the likelihood of staying in rural and remote areas and all agreed that doing the course resulted in increased job satisfaction. The majority (87%) of the students rated the course as excellent or very good and all of them said that they would recommend the course to others. Conclusions: These results suggest that rural and remote paramedics have the opportunity and desire to incorporate more health promotion and prevention into their practice and that this course has provided them with the skills and knowledge to do so. The curriculum is based on National Health Priority Areas focusing in particular on lifestyle change to prevent and manage chronic disease. This means that in rural and remote areas, all health professionals can use a common framework to work together to enhance primary health care and chronic disease management as a multidisciplinary team.     

GP Clinic: promoting access to primary health care for mental health service clients

Objective: To evaluate an innovative rural service offering comprehensive primary health care for mental health service clients. Design: A formative evaluation using mixed methods. Setting: A rural NSW community. Participants: Fifteen health care providers and 120 adult clients. Intervention: A monthly clinic held in a general practice to provide primary health care for clients of the community mental health team. Main outcome measures: Client utilisation and clinic activity data. Provider views of service effectiveness, possible improvements and sustainability. Results: The GP Clinic has operated successfully for 2.5 years without access block. Some 52% of clients had no physical illness and 82% were referred to other health and community services. In total, 40% continued to attend the clinic while 32% went on to consult a GP independently. Client access to care improved as did collaboration between the community mental health team and primary care providers. Conclusion: The GP Clinic is a straightforward and flexible service model that could be used more widely.     

Why do junior doctors not want to work in a rural location,and what would induce them to do so?

Objective: Identify the most important factors associated with choosing rural medical practice. Design: Cross‐sectional design using a web survey to collect quantitative and qualitative data. Participants: One hundred and ninety junior doctors – 91 interns, 99 PGY2. Main outcome measures: Choice of practice location (urban/rural), reason for choosing location, enticement to a rural location. Results: Twenty‐seven per cent of junior doctors preferred a rural practice location. Preference to practice in a rural area was associated with medical placement bonding schemes, rural background, rural placement experience and being older. High levels of professional expectations and prestige were associated with a preference for an urban location. The most important reasons for choosing a practice location included consideration of partner, family and friends (35.3%), preference for a location (20.5%), lifestyle goals (19.5%) and career opportunities, specialty requirements and infrastructure (17.9%). Those who preferred an urban compared with a rural location gave more importance to factors concerning partner, family and friends. The factors that would entice a doctor to a rural location included partner and family considerations (27.0%), professional support (20.3%), and career opportunities, specialty requirements and infrastructure (16.3%). Women gave more importance to partner and family factors than men. Conclusions: Our findings support the continuation of policies that are known to encourage choice of rural practice, but highlight the need for additional strategies that consider the personal and professional needs of this generation of doctors.     

Assessment of Pharmacists' Perception of Patient Care Competence and Need for Training in Rural and Urban Areas in North Dakota

Context: Few studies have examined pharmacists' level of patient care competence and need for continuous professional development in rural areas.
Purpose: To assess North Dakota pharmacists' practice setting, perceived level of patient care competencies, and the need for professional development in urban and rural areas.
Methods: A survey was mailed to all 686 North Dakota pharmacists and included items regarding practice setting, competency areas, and the need for certificate programs.
Findings: Overall, 401 of 686 (58.5%) surveys were returned and 364 responses were usable. Three practice settings (independent community pharmacies [47.3%], chain stores [13.2%], and hospital pharmacies [22.8%]) comprised 83.3% of the sample. More independent community pharmacists were located in rural areas than urban areas ( P < .01). More respondents had a Doctor of Pharmacy (PharmD) degree in urban areas (40.8%) compared to those in rural areas (15.1%) ( P < .01). Pharmacists in urban areas rated 18 of 33 competencies higher than did pharmacists in rural areas ( P < .01). Pharmacists with a Bachelor of Science degree reported a lower level of preparation than did PharmD trained pharmacists. Although not statistically significant, 28.2% of pharmacists perceived a patient care certificate as a need and a greater percentage were from rural than urban areas.
Conclusion: The findings should be interpreted to be primarily due to differences in practice setting and degree earned that were most prevalent in urban and rural areas. Training mode needed most is through the certificate program, particularly by rural pharmacists who reported a lower level of preparation on perceived patient care-related items than did urban pharmacists.     

The Primary Care Physician Workforce in Massachusetts: Implications for the Workforce in Rural,Small Town America

ABSTRACT: Context: Small towns across the United States struggle to maintain an adequate primary care workforce. Purpose: To examine factors contributing to physician satisfaction and retention in largely rural areas in Massachusetts, a state with rural pockets and small towns. Methods: A survey mailed in 2004‐2005 to primary care physicians, practicing in areas designated by the state as rural, queried respondents about personal and practice characteristics as well as workforce concerns. Predictors of satisfaction and likelihood of remaining in current or rural practice somewhere were assessed. Findings: Of 227 eligible physicians, 160 returned their surveys (response rate, 70.5%). Approximately one third (34.0%) reported they had grown up in communities of 100,000 or larger. Factors associated with higher overall practice satisfaction included not feeling overworked (P = .043) or professionally isolated (P = .004), and being involved in their practice (P = .045) and home communities (P = .036) as well as ease of seeking additional physicians for practice and obtaining CME credits (P = .014 and P = .017, respectively). Female physicians were more likely to report an intention to remain in rural practice somewhere for the next decade (P = .034). In rating their satisfaction with various aspects of the rural practice environment, physicians reported greatest satisfaction with their practice overall (67%) and their call group size (66%). They were least satisfied with their current (30%) and likely future income (40%). In multivariate analyses, larger practice community size was positively related to the dependent variable of overall satisfaction and negatively related to likelihood of staying in current practice or in rural practice somewhere. Conclusions: Our findings reaffirm the importance of rural medical education opportunities in physician recruitment, retention, and practice satisfaction. They also indicate that in a small New England state, a major source of physicians for rural and small town communities is physicians who have been raised in urban/suburban communities and who were trained outside of the region but who were prepared to live and to practice in rural and small town communities.     

Recruitment and retention issues for occupational therapists in mental health: Balancing the pull and the push

Background/aim: Recruitment and retention issues for mental health occupational therapists have been the subject of significant concern for many years. This paper describes recruitment and retention issues as reported by mental health occupational therapists employed by a large Area Health Service in metropolitan Sydney. Method: Thirty‐eight mental health occupational therapists (response rate 84%) completed a survey in the first half of 2008. Key themes investigated were: overall satisfaction; attractive elements of positions; positive aspects of positions; constraints of positions; factors associated with leaving positions; supervision; professional development; career pathways; and interest in and access to management positions. Results: Key elements that kept respondents in positions included the nature of the work, being in a supportive team and the opportunity to use occupational therapy skills. Elements that prompted people to consider leaving positions were the desire for new and different types of work, a desire to work closer to home, insufficient time or high workloads, feeling ‘bored’ or ‘stale’, organisational change or juggling multiple demands, working in unsupportive or dysfunctional teams and family or other personal factors. Conclusions: The results supported the development of a ‘push and pull’ conceptualisation of recruitment and retention issues, including job‐related (intrinsic) and non‐job‐related (extrinsic) issues. This conceptualisation allows organisations to closely examine factors that attract practitioners to positions and those that support or damage staff tenure.     

Going rural but not staying long: Recruitment and retention issues for the rural dietetic workforce in Australia

Aim: To determine the recruitment and retention issues for rural based dietetic services. Methods: A sequential explanatory mixed methods approach was used to examine six case study sites of dietetic practice, in a geographical area covering 30 000 km² in rural New South Wales, Australia. Quantitative data were obtained from document searches of human resource records between 1991 and 2006. Data were tabulated and counts and proportions used. Qualitative data were obtained from in-depth semistructured individual interviews conducted with 40 key informants including past and present dietitians (n = 28), dietetic managers (n = 3), health service managers (n = 6) and other key influencers (n = 3). The interviews were thematically analysed using the NVivo 7 program. Themes were coded into common categories, using a constant comparison inductive approach. Results: Ninety individual dietitians (94% female) were employed across the six sites over 15 years. The majority were new graduates with less than 1 year of experience. Approximately one-third remained in their position for less than 6 months while 32% remained for 2 years or longer. Key themes emerged from the qualitative data around the characteristics of a rural role, line management of dietitians in a rural site and establishing and maintaining rural staff. Conclusion: Recruitment and retention in rural areas may be improved in the future through strategies to reduce perceived professional isolation, improve management support, access to continuing education and the development of career pathways.     

Care management for depression in primary care practice: findings from the RESPECT-Depression trial

PURPOSE This qualitative study examined the barriers to adopting depression care management among 42 primary care clinicians in 30 practices.METHODS The RESPECT-Depression trial worked collaboratively with 5 large health care organizations (and 60 primary care practices) to implement and disseminate an evidence-based intervention. This study used semistructured interviews with 42 primary care clinicians from 30 practice sites, 18 care managers, and 7 mental health professionals to explore experience and perceptions with depression care management for patients. Subject selection in 4 waves of interviews was driven by themes emerging from ongoing data analysis.RESULTS Primary care clinicians reported broad appreciation of the benefits of depression care management for their patients. Lack of reimbursement and the competing demands of primary care were often cited as barriers. These clinicians at many levels of initial enthusiasm for care management increased their enthusiasm after experiencing care management through the project. Psychiatric oversight of the care manager with suggestions for the clinicians was widely seen as important and appropriate by clinicians, care managers, and psychiatrists. Clinicians and care managers emphasized the importance of establishing effective communication among themselves, as well as maintaining a consistent and continuous relationship with the patients. The clinicians were selective in which patients they referred for care management, and there was wide variation in opinion about which patients were optimal candidates. Care managers were able to operate both from within a practice and more centrally when specific attention was given to negotiating communication strategies with a clinician.CONCLUSIONS Care management for depression is an attractive option for most primary care clinicians. Lack of reimbursement remains the single greatest obstacle to more widespread adoption.     

Role of multi-purpose service programs providing residential aged care in rural Australia: a discussion paper

Objective: To determine if multi‐purpose service (MPS) Programs deliver improved residential aged care as opposed to traditional rural hospitals. Design: A variation on comparative–experimentalist: type 4. In this design 2 groups providing different service models of rural health services are compared. Setting: Six MPS Programs and three traditional hospitals in rural New South Wales. Subjects: Key stakeholders – area representatives, health service managers, MPS managers, doctors, staff, MPS or hospital committee members and consumer groups including residents. Main outcome measure: To analyse the ability of MPS Programs to deliver quality residential aged care as opposed to using traditional hospitals for such services. Results: Multi‐purpose service programs provided better residential environments and greater flexibility of service provision. There were few apparent differences between the two service models in regard to organisational culture and training. Conclusions: The findings of this evaluation suggest that in the provision of residential aged care in rural communities, MPS Programs demonstrated better standards of care than traditional hospital based services. What is already known on the subject: The development of multi‐purpose service programs to replace the older traditional rural hospitals is a relatively new practice in Australia. With the introduction of MPS programs there has been little evaluative research to demonstrate their effectiveness in health service delivery and the provision of residential aged care. Multi‐purpose service programs aim to integrate and coordinate acute, aged and community rural health services under one structure and so it is imperative that evaluative studies such as this one takes place. What does this study add?: The findings of this study demonstrate that the MPS model provides a better solution than hospitals to the problem of providing residential aged care in rural communities. With Australia looking to further develop MPS Programs in rural areas, it is hoped quality aged care services will be enhanced allowing older adults to remain in the communities of their choice.     

How do registered nurses define rurality?

Objective: The objective of this analysis was to identify the meaning of rurality for registered nurses (RNs) practising in rural and remote Canada. Setting and design: An existing Statistics Canada definition was used to stratify Canada's 10 provinces into urban and rural areas. As part of a national multi‐method study, a random sample of RNs in these rural strata, plus all RNs working in outpost settings and northern territories, were surveyed concerning the nature of nursing practice. Content analysis was used to identify themes from an open‐ended question: ‘How do you define rural/remote?’ Refinement of the themes was conducted by the survey team and credibility was supported through investigator triangulation. Participants: Of the 3933 RNs who responded to the survey (68% response rate), 3412 provided a definition of rural/remote. A subsample of 1285 RNs was used for detailed thematic analysis because these respondents provided definitions with a clear referent to rural and/or to remote; the remaining sample was used for verification of themes. Results: Four defining themes were identified by RNs for both rural and remote: community characteristics, geographical location, health human and technical resources, and nursing practice characteristics. Conclusions: The themes can be used as content domains or dimensions of rurality to improve our understanding of how to describe rural communities, including geographical location and nursing practice, from the perspective of RNs.     

New Zealand rural primary health care workforce in 2005: more than just a doctor shortage

OBJECTIVE: To obtain a 2005 snapshot of New Zealand (NZ) rural primary health care workforce, specifically GPs, general practice nurses and community pharmacists. DESIGN: Postal questionnaires, November 2005. SETTING: NZ-wide rural general practices and community pharmacies. PARTICIPANTS: Rural general practice managers, GPs, nurses, community pharmacy managers and pharmacists. MAIN OUTCOME MEASURES: Self-reported data: demographics, country of training, years in practice, business ownership, hours worked including on-call, intention to leave rural practice. RESULTS: General practices: response rate 95% (206/217); 70% GP-owned, practice size ranged from one GP/one nurse to 12 GPs/nine nurses. PHARMACIES: Response rate 90% (147/163). Majority had one (33%) or two (32%) pharmacists; <10% had more than three pharmacists. GPs: response rate 64% (358/559), 71% male, 73% aged >40, 61% full-time, 79% provide on-call, 57% overseas-trained, 78% male and 57% female GPs aged >40; more full-time male GPs (76%) than female (37%) . Nurses: response rate 65% (445/685), 97% female, 72% aged >40, 31% full-time, 28% provide on-call, 84% NZ-trained, 45% consulted independently in 'nurse-clinics' within practice setting. Pharmacists: response rate 96% (248/258), 52% male, 66% aged >40, 71% full-time, 33% provide on-call, 92% NZ-trained, 55% sole/partner pharmacy owners. Many intend to leave NZ rural practice within 5 years: GPs (34%), nurses (25%) and pharmacists (47%). CONCLUSION: This is the first NZ-wide rural workforce survey to include a range of rural primary health care providers (GPs, nurses and pharmacists). Ageing rural primary health care workforce and intentions to leave herald worsening workforce shortages.