a report for the winston churchill memorial trust of australia · intended audience general...
TRANSCRIPT
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To investigate new approaches to strengthen social connection of newly-arrived health workers in rural Australia – Canada
A Report for the Winston Churchill Memorial Trust of Australia
Dr Cath(erine) Cosgrave 2018 Jack Brockhoff Foundation Churchill Fellow
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Indemnity
I understand that the Churchill Trust may publish this Report, either in hard copy or on the
internet or both, and consent to such publication.
I indemnify the Churchill Trust against any loss, costs or damages it may suffer arising out of
any claim or proceedings made against the Trust in respect of or arising out of the
publication of any report submitted to the Trust and which the Trust places on a website for
access over the internet.
I also warrant that my final report is original and does not infringe the copyright of any
person, or contain anything which is, or the incorporation of which into the final report is,
actionable for defamation, a breach of any privacy law or obligation, breach of confidence,
contempt of court, passing-off or contravention of any other private right or of any law.
Catherine Cosgrave 13 September 2019
Dr Cath(erine) Cosgrave PhD, MA, B.Com Research Fellow – Allied Health and Nursing Rural Health Workforce Department of Rural Health Faculty of Medicine, Dentistry and Health Sciences The University of Melbourne Docker St, Wangaratta VIC 3677 [email protected] (work) [email protected] (personal) +61 0405 100 897 (mobile) Twitter: @CathCos1 Linkedin.com/in/cath-Cosgrave-23346a85
The views expressed and the recommendations made within this report are mine as a Churchill Fellow, and are not endorsed by my employer and no attempt has been made to obtain such endorsement.
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Acknowledgements
Firstly, I wish to thank the Jack Brockhoff Foundation and the Winston Churchill Trust for
providing me with this amazing opportunity to travel to Canada to investigate an issue that I
am so passionate about.
I wish to thank all the academics, health professionals, recruiters, government personnel and
community members whom I interviewed and were so generous with their time and sharing
their thoughts and understanding. I hope that I have been able to convey accurately both
your achievements and challenges. I so enjoyed the warm-hearted, kind and courteous spirit
of Canadians and your huge big gorgeous land.
In particular, I would like to state my gratitude to A/Prof Judy Gillespie and Prof Roger
Strasser who have both unfailingly supported me and promoted this research from the
outset. I look forward to continuing our conversations and developing international research
collaborations on recruitment and retention of rural health workforce.
I would like to thank Professors Myfanwy Maple and David Perkins for their ongoing support
and commitment to this research and for being my referees for this application. I thank Prof
Lisa Bourke for supporting this Fellowship and for granting the two month’s study leave it
required.
To my husband Bruce Naylor, thank you for your unfailing support and being my constant
sounding board over the last seven years as I try to deeply understand this complex issue
and find solutions that will make a real and lasting difference to the lives of rural Australians.
I am so glad you got to be my side for this part of the journey. And while we were in Canada,
thank you for managing all the driving, bag carrying, cooking, photography, travel research
and budgeting to enable me to say ‘yes’ to all the fabulous opportunities that this Fellowship
presented.
A big thank you to those that assisted in the production of this Report: Rosemary Dore for
the design of the cover and keywords pages; Jo Dolan for the editing and again to my
husband Bruce, for the photo collage pages and all the diagrams.
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Key Words
Rural & Remote
Social Connection Recruitment &
Retention
Community Engagement
Sense of Belonging
Sense of Place
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Table of Contents
Executive Summary.................................................................................................................... 2
Glossary of Terms ...................................................................................................................... 5
Introduction ................................................................................................................................. 6
Background ................................................................................................................................ 6
Itinerary ....................................................................................................................................... 5
Findings ...................................................................................................................................... 9
Case Study –– Recruiter and Community Connector Model, Marathon, Ontario ..................... 25
Photo Collage ........................................................................................................................... 27
Discussion ................................................................................................................................ 29
Recommendations and Dissemination Plan ............................................................................. 33
Conclusion ................................................................................................................................ 38
Appendix A –Canada – Political Map ....................................................................................... 40
Appendix B – Rural Health Workforce Pipeline ........................................................................ 41
References ............................................................................................................................... 42
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Executive Summary
Introduction
Rural health workforce shortages are a wicked problem and a major reason for poorer health
and shorter lifespans of rural Australians compared to their city counterparts. Recently
published studies, including my own, have identified the importance of psychosocial factors
on retention and the need for a community engagement approach to successfully attract,
recruit and retain a rural health workforce. In particular there is an urgent need for rural
communities to support newcomer health workers to socially connect and develop a sense
of belonging.
I was awarded the 2018 Jack Brockhoff Foundation Churchill Fellowship to travel to Canada
to investigate new approaches to strengthen social connection of newly-arrived health
workers in rural Australia. The Canadian trip had two objectives:
• to increase knowledge of successful approaches being used in rural Canada to
actively support ‘newcomer’ health workers to improve their social connection and
sense of belonging; and
• to increase my knowledge of innovative ‘grow-your-own’ workforce strategies,
especially those focused on Indigenous workers (this objective was added after the
Fellowship was awarded given the opportunity to visit Nunavut a remote areas of
Canada.
Intended Audience
General audience public, health professionals, private and public health services and
government departments and politicians in Australia and in other high-income countries
concerned about and/or actively involved in addressing heath workforce shortages and high
turnover negatively affecting the health wellbeing of rural and remote communities.
Highlights and Achievements
The key highlights and achievements of my Fellowship were:
• the establishment of an Australian–Canadian research partnership to progress
understanding of the role sense of place has in attracting and retaining health
professionals to work and live in rural settings;
• the identification of the Recruiter and Community Connector Model successfully
operating in Marathon Ontario for the last 13 years;
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• the identification of the grow-your-own workforce strategy – the Educational
Upgrade Program being implemented by the Department of Health, Government of
Nunavut to support the educational and career advancement of Indigenous staff;
• being linked into an international network through the Recruit & Retain – Making it
Work study of people working in universities, rural health services, communities and
government departments involved in strengthening understanding of community
engaged approaches to attracting and retaining health professionals to live and work
in rural and remote communities.
Recommendations
To strengthen a community engaged approach for addressing rural health workforce issues,
there is an urgent need for: collaboration to strengthen the evidence-base; education and
strengthened understanding on the importance of community engagement in addressing
rural health workforce issues; and trialling of innovative community-based models. To
progress these priorities, I propose the following ten recommendations be implemented:
Collaboration among rural and remote communities across different countries to strengthen the evidence base
1) Through the development of the established Australian–Canadian partnership: a) strengthen understanding of the role sense of place has in the retention of professionals working in health and social service government sectors in rural settings; and b) seek research funding to undertake mirror research in each country to identify what elements of sense of place have utility for curriculum development, workforce planning, and community development.
2) Undertake an environmental scan in Australia to identify current/previous community engaged approaches/models aimed at addressing rural health and social service workforce issues, complete a desk-based evaluation to assess their effectiveness and efficiency, and write-up and share any successful case studies (see Recommendation 9).
3) Strengthen links made with rural and remote communities across different countries involved in community engaged approaches to recruitment and retention, particularly those northern countries involved in the Recruit & Retain – Making it work study, with the aim to establish an information sharing network of innovative approaches being trialled, evaluation results and case studies of successful approaches.
Education and strengthened understanding among key stakeholders in Australia on the importance of, and urgent need for, community engagement in addressing rural health workforce issues 4) Seek opportunities to run participatory workshops with rural communities to
present the whole-of-person retention improvement framework for the purpose of building understanding of the need for a community engaged approach for addressing rural health workforce issues and undertaking group work to develop context-informed community engaged strategies to inform the local town or region’s health workforce development planning.
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5) Seek opportunities to build understanding of the Executive and Human Resources personnel working in rural health services and personnel from relevant Government departments on the evidence for adopting a community engaged approach to effectively address rural health workforce issues, and to promote the whole-of-person retention improvement framework and the recruiter and community connector model (through presentations or keynote addresses at national conferences, media interviews, and in peer-reviewed publications).
6) Seek opportunities to meet with relevant Australian Government Ministers (e.g. Health, Social Services, Regional Development, Indigenous Affairs) and key government appointments (e.g. Rural Health, National Rural Health Commissioner) to build understanding of the needs case for a community engaged approach for addressing rural and remote health workforce shortages and turnover, and lobbying for funding to support a longitudinal trial of the recruiter and community connector model in regional, rural and remote communities across Australia.
Trialling innovative community-based models aimed at strengthening and stabilising rural health workforce, in regional, rural and remote communities across Australia
7) Identify rural and remote communities in Australia interested in trialling the Recruiter and Community Connector Model as a whole-of-community with major employers including health services and local councils willing to make a financial commitment to funding the Community Connector position for a minimum of five years.
8) Conduct a longitudinal evaluation study (for a minimum of seven years) on the rural communities involved in trialling the Recruiter and Community Connector Model. The evaluation will involve: collecting baseline data on current workforce shortages, turnover and retention rates; implementing tools and measures to assess effectiveness and efficiency of the model; and collecting qualitative data to write-up and share successful case studies and help build the evidence base.
9) Create a website on community engaged approaches addressing rural health workforce issues to provide resources including national and international case studies, examples of resources developed, publications and presentations of the research evidence etc. for use by the rural communities involved in trialling the Recruiter and Community Connector Model and other interested stakeholders, including other countries participating in the information sharing network (see Recommendation 3).
10) Conduct an initial and annual conference for the duration of the trial to encourage innovation and success and support through networking opportunities to the rural communities involved in trialling the Recruiter and Community Connector Model. The conferences would include: international and national keynote speakers, presentations on evidenced-informed best practice approaches and sharing by the communities on their successes and failures.
Contact details Dr Cath(erine) Cosgrave PhD, MA, B.Com [email protected] (work) [email protected] (personal) +61 0405 100 897 (mobile)
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Glossary of Terms
CASPR Canadian Association of Staff Physician Recruiters
CSA Casual Staffing Action
EUP Educational Upgrade Program
LICC Longitudinal integrated community clerkships
MFHT Marathon Family Health Team
MPRRC Marathon Physician Recruitment and Retention Committee
NOHRA Northwestern Ontario Health Recruiters Association
NOSM Northern Ontario School of Medicine
NSW New South Wales
PA Physician Assistant
RN Registered Nurse
SARRAH Services for Australian Rural and Remote Allied Health
SLRPS Sioux Lookout Regional Physician Services
UBC University of British Columbia
UDRH University Departments of Rural Health
UNBC University of Northern British Columbia
WHO World Health Organization
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Introduction
The purpose of my Churchill Fellowship and Canadian trip was to investigate innovative
approaches to attracting, recruiting and retaining health workers in regional, rural and remote
areas. The project aim was to increase my knowledge of successful approaches being used
in rural Canada to actively support ‘newcomer’ health workers improve their social
connection and sense of belonging. Given the need for multiple strategies to address the
‘wicked’ problem of rural health workforce shortages, especially in remote Australia, and the
opportunities to visit remote areas of Canada (namely Nunavut), I expanded the project
objective to include increasing my knowledge of innovative ‘grow-your-own’ workforce
strategies, especially those focused on Indigenous workers.
Background Compared to their city counterparts, Australians living in rural and remote areas have shorter
lifespans, report higher levels of chronic disease and injury, and have poorer access to and
less usage of health services[1]. A major contributing factor is rural1 health workforce
shortages and high turnover, particularly of allied health professionals, with considerable
direct and indirect costs[2, 3]. In rural Australia, there are fewer doctors and medical
specialists and the nursing workforce is the mainstay of health care and allied health2
professionals are crucial in providing effective preventative and cost effective care[4-6].
While rural health workforce shortages are a global concern, countries like Australia and
Canada, with large land masses and small, broadly dispersed rural communities, face
additional challenges achieving adequately staffed rural health services[7]. In rural Australia,
public health is heavily relied upon as there is limited access to private health services,
which intensifies with remoteness[8].
Since 2000, the Commonwealth Government has significantly invested in strategies to
address rural health workforce shortages and this has resulted in some workforce
improvements, particularly for doctors in the primary care settings; however, shortages of
allied health and nursing professionals persist[4]. This urgent need to address rural allied
1 The use of term ‘rural’ includes regional and remote.
2 There is no universally accepted definition of ‘allied health workforce’ but there is general agreement that
it includes health professions that are NOT medical, dental or nursing professions, and professionals
involved in prevention and management of chronic and acute health conditions such as physiotherapists,
social workers, occupational therapists, dieticians, medical imagers, and pharmacists.
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health workforce shortages and high turnover has recently been highlighted by the
National Rural Health Commissioner’s public consultation in 2019 to guide Commonwealth
Government policy reform and investment to improve the quality, access and distribution of
Australia’s rural allied health workforce[9]. The Commissioner has stated that ‘ new training
and workforce framework is warranted for producing an effective and supported rural allied
workforce’[9].
Previous research into factors affecting the retention of rural allied health and nursing
professionals identifies the decision to stay or leave as a complex interaction between
workplace conditions, career building opportunities, and psychosocial and personal factors
(especially life stage aspects)[10, 11]. The majority of retention studies have focused on the
influence of workplace conditions, including career building factors, ignoring these inter- and
intra-personal determinants. In a scoping literature review study I undertook with two
colleagues on the existing rural allied health, nursing, and medical workforce literature
addressing the influence social determinants on retention, the thematic analysis undertaken
identified a process of integration and adaptation involving four place-based social
processes: (1) rural familiarity and/or interest, (2) social connection and place integration, (3)
community participation and satisfaction, and (4) fulfilment of life aspirations[12]. A synthesis
of the findings is presented in the following figure.
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Figure 1: Conceptual framework of the social determinants of rural health workforce retention. Source: Cosgrave et al. (2019) [12]
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Development of the whole-of-person retention improvement framework My doctoral research developed a theory explaining the factors influencing the turnover
intention of early career3 allied health and nursing professionals working in rural New South
Wales (NSW) public health services[13]. The turnover intention theory provided a whole-of-
person explanation of turnover intention. It was developed based on an identified core
category of professional and personal expectations being met and an identified basic social
process of adjusting to change involving various stages: Initial adjustment (Stage 1 –
Becoming familiar with the workplace); Continuing adjustment (Stage 2 – Gaining mastery of
the job); Having adapted (Stage 3 – Being comfortable in the job and living in the
community/town); and Weighing it all up (Stage 4 – Deciding whether to stay or leave job
and town) – see Figure 2 below.
Figure 2: Cosgrave PhD study – Basic social process – adjusting to change
My theory proposed that an individual’s decision to stay or leave their job was determined by
the meeting of life aspirations, and this related to the extent of the gap between individuals’
professional and personal expectations and the reality of their current employment and rural
living experience. The extent of individuals’ professional and personal expectations can be
measured by their satisfaction levels (see Figure 3).
3 'Early-career' is a term commonly used in Australia’s health sector to refer to the first five years of working in
a professional role after completing tertiary level qualifications but, as the study was focused on the ‘first few
years of working’, early career was further classified into two levels of experience: beginner (0–3 years) and
intermediate (3–5 years).
•4-12mths
•Learning the job
• 0-3mths
• Rabbit in the headlights
•13mths
•Comfortable in the job/town
Initial Adjustment Longer-term
Adjustment
Having Adapted
Weighing it all up
Deciding whether to stay or go
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Figure 3: Cosgrave PhD study – Conceptualisation of turnover intention theory
A major finding was that in the adjustment stages (initial and continuing), turnover intention
was most strongly affected by professional experiences, in particular those relating to the job
role, workplace relationships and level of access to continuing professional development. In
these adjustment stages, personal satisfaction mostly concerned those with limited social
connections in the town – primarily newcomers. Having reached the ‘having adapted’ stage,
the major influence on turnover intention shifted to personal satisfaction, and this was
strongly impacted by individuals’ life stage.
The significance of life stage is supported by Erikson’s three stages of adulthood: young,
middle and late[14]. Young adulthood, which generally occurs in the early-mid 20s, is a
highly mobile time of life and concerned with having new experiences, career advancement,
social activities and pair-bonding. Middle adulthood generally commences in the mid-late
20s and is a more stable time of life, interested in settling down and, for many, having a
family and concerned with achieving a work-life balance. By drawing on the turnover
intention theory and the basic social process, I developed a risk assessment matrix of
individuals’ turnover intention and identified three levels of risk: highly vulnerable, moderately
vulnerable and not very vulnerable. The most vulnerable workers were those in early career
(beginners 0–3 years), in early adulthood and who were newcomers.
These findings led to the development of a whole-of-person rural retention improvement
framework outlining what is required across the three life domains (workplace/organisational,
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role/career building, and community/place) to support high-levels of professional and
personal satisfaction among health professionals.
Figure 4: Cosgrave – Whole-of-person rural retention improvement framework
The aim of the whole-of-person retention improvement framework is to increase the job and
personal satisfaction of rural health workers by ensuring that:
• newly-recruited rural health workers are warmly welcomed at the start of their
employment and their settling-in needs are understood and addressed;
• rural health workers’ personal and professional wellbeing is supported in an ongoing
way in the workplace and by the organisation;
• rural health workers have regular access to continuing professional development
training (both internal and external) and career building work opportunities
appropriate to their career stage and professional interests; and
• that newly-arrived rural health workers are supported to develop strong social
connections, both in the workplace and in the broader local rural community,
appropriate to their life stage, personal circumstances and interests.
By developing strategies informed by my whole-of-person rural retention improvement
framework and tailored for the specific context of the rural health service and community,
avoidable turnover within the allied health public health workforce can be reduced.
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The whole-of-person rural retention improvement framework has been qualitatively
tested with two public health services operating in rural Victoria for the last two-years
(September 2017–December 2019). The project is a co-funded partnership between The
University of Melbourne, Department of Rural Health where I am employed as a Research
Fellow, and two Victorian rural public health services – Goulburn Valley Health (a large
regional health service) and East Grampians Health Service (a small rural health service).
The project aim is to develop strategies focused on improving job and personal satisfaction
of early career allied health workforce with the aim of improving retention. The project uses a
community-based participatory action research methodology which involves stages of
planning, acting, observing and reflecting that occur cyclically and lead to further inquiry
and/or new actions for change. The purpose is to gather research findings that are context-
informed, and which can be translated into actions to support local change as well as
strengthen local knowledge[15].
The preliminary project results confirm the generalisability and validity of the whole-of-person
rural retention improvement framework for assisting public sector rural health services to
better understand, measure and implement approaches to improve the job and personal
satisfaction of their allied health staff.
While there has been a strong evidence base to draw on to implement a whole-of-person
approach in the workplace/organisational and role/career building domains, as discussed
above, there has been little research with respect to the community/place domain conducted
in the health sector. So, there is an urgent need to develop a deeper understanding of
placed-based belonging and health workforce case studies on strategies that have been
effective in improving the social connection of newcomer rural health workers.
The aim of my Churchill Fellowship project was to address this knowledge gap by travelling
to Canada to identify effective approaches to strengthening social connection and
belongingness of newly-arrived rural health workers. Canada was selected because I
considered the replicability of initiatives to be likely given both countries have similar public
health systems, population distributions and geographic challenges.
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Itinerary My trip to Canada primarily involved visiting two provinces – Ontario (in particular the region
of Northern Ontario) and British Columbia and the Territory of Nunavut located in the article
circle. Short visits were also made to the provinces of Alberta and Quebec (see Appendix A
– Political Map of Canada).
Dates/place Interviews Activities
30 April–4 May 2019
Sudbury, Ontario Dr Maurianne Reade (MD), Physician Manitoulin Central Family Health Team, Mindemoya Clinic, Associate Professor, NOSM
Tour of health services on Manitoulin Island
Ms Angela Recollet, Executive Director Shkagamik-Kwe Health Centre
Tour of Shkagamik-Kwe Health Centre (Aboriginal Health Access Centre)
Ms Jennifer Turcotte-Russak, Manager, Community Engagement & Integrated Clinical Learning, NOSM – Rehabilitation Studies and Northern Studies Stream Mr Robert Barnett, Administrative Director, Community Engagement & Integrated Clinical Learning, NOSM – Rehabilitation Studies and Northern Studies Stream
Part of an international delegation (Scotland, USA, Australia) visiting to the Northern Ontario School of Medicine (NOSM) Laurentian University campus Scottish delegation: Health Workforce & Leadership and Service Reform Directorate Prof Emma Watson, Director of Medical Education NHS Highland, Inverness, United Kingdom The University of Dundee Prof Maggie Bartlett , Chair of Education in General Practice, Head of GP Undergraduate Education, Dundee, United Kingdom Prof Jon Dowell, ScotGEM, Programme Director, University of St Andrews, St Andrews, United Kingdom
Dr Sarah Newbery (MD), Physician Marathon Family Health Team, Associate Professor NOSM, Co-Chair Northern Physician Resources Task Force
Attended Northern Constellations 2019, NOSM faculty development conference, Holiday Inn, Sudbury, 3–4 May 2019 Sessions: Blanket Exercise: Exploring Canadian Indigenous History, Theatre and Conversations with Debajehmujig Storytellers, Cultural Humility and Care of Indigenous Peoples
Attended Celebrating Success with NOSM, Sudbury community gathering to
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Dates/place Interviews Activities
recognise the contributions of Dr. Roger Strasser, Founding Dean and CEO, 2 May
7–11 May 2019
Thunder Bay, Ontario Dr Roger Strasser (MD), Prof of Rural Health CEO and Dean NOSM @ Lakehead University (Thunder Bay) & Laurentian University (Sudbury)
Attended National Nurses Week 2019 Celebration, launch of local digital stories about compassion in nursing, Lakehead University, 8 May
Dr Penny Moody-Corbett, Associate Dean, Research, NOSM, Lakehead University
Celebrating Success with NOSM, Thunder Bay community gathering to recognise the contributions of Dr Roger Strasser, Founding Dean and CEO, 8 May
Dr Sarah Strasser (MD), Head of Rural Clinical School, Rural Clinical School Faculty of Medicine, University of Queensland
Dr Glenna Knutson (PHD), Director Nursing, School of Nursing, Lakehead University and Assoc Prof Karen Poole, School of Nursing, Lakehead University and staff
Ms Carmen Blais, Clinical Co-ordinator for Heath Co-op, Matawa First Nation Management and staff
Dr. Valerie Grdisa (PhD), Executive Vice President, Research, Quality & Academics/Chief Nursing Executive, Thunder Bay Regional Health Sciences Centre
Mr Jamie Sitar, Physician Recruitment & Retention Specialist, Thunder Bay Regional Health Sciences Centre ex Sioux Lookout Physician Services Inc
Ms Jennifer Wakegijig, Senior Project Consultant Office of the Dean, NOSM
12–13 May 2019
Ottawa, Ontario Mr Brett Redden, Physician and health professional recruiter and locum coordination services (Contractor position), Marathon, Ontario
14–19 May 2019
Iqaluit, Nunavut Ms Charleen Austen, Assistant Deputy of Health Operations, Department of Health, Nunavut
Invited guest speaker Department of Health, Nunavut, gave 1hr presentation on 15
May to staff. Title: Retention of healthcare professionals in rural
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Dates/place Interviews Activities
Australia: Current research and implications for Canada
Dr Stephen Tuitt (MD), Territorial Director, Medical Affairs, Department of Health, Government of Nunavut Dr Francois de Wet (MD), Territorial Chief of Staff, Medical Affairs, Department of Health, Government of Nunavut Ms Jennifer Pearce, Clinical Nurse Educator, Department of Health, Government of Nunavut
23–26 May 2019
Prince George, British Colombia
Dr Martha MacLeod (PhD), Professor, School of Nursing & School of Health Sciences, Northern Health-UNBC Knowledge Mobilization Research Chair, Co-Lead UNBC Health Research Institute, University of Northern British Columbia (UNBC) and members of the Nursing Practice in Rural and Remote Canada II research team
Invited guest speaker by UNBC to present to UNBC staff & members of Northern Health-UNBC Knowledge Mobilization Research Group. Gave 1hr presentation on 24 May. Title: Trialling a whole-of-person approach for improving retention of rural-based health professionals: Current Australian research and implications for Canada
Dr Joanna Pierce (PhD) Social Work Director, Field Education, UNBC
Dr Paul Winwood (MD), Regional Associate Dean Northern British Columbia, University of British Columbia, Associate Vice President Northern Medical Program, UNBC
28 May–5 June 2019
Kelowna, British Colombia
Dr Judy Gillespie (PhD) Associate Professor, School of Social Work, Faculty of Health and Social Development, The University of British Columbia (UBC), Kelowna campus, Okanagan
7–10 June 2019
Vancouver, British Columbia
Dr Maggie Watt (MD) Program Director Integrated Community Clerkship (ICC) Cowichan District Hospital, Faculty of Medicine, The University of British Columbia
Bob Bluman (MD) Acting Associate Dean/Executive Medical Director, Continuing Professional Development
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Dates/place Interviews Activities
Clinical Professor, Department of Family Practice, Faculty of Medicine, The University of British Columbia
Ms Audra Fediurek Executive Director Health Match BC – Division of the Health Employers Association of British Columbia
11–19 June
Calgary & Edmonton, Alberta
Dr Aaron Johnston (MD) Director of Distributed Learning and Rural Initiatives, Clinical Associate Professor Emergency Medicine and Family Medicine, Cumming School of Medicine, University of Calgary
2019 Thinking Qualitatively Workshop Series, International Institute for Qualitative Methodology, University of Alberta, attended 2 workshops 15-16 June
Dr Douglas Myhre (MD) Associate Dean Distributed Learning and Rural Initiatives, Cumming School of Medicine, University of Calgary
20–21 June
Montreal, Quebec Ms Yvonne Hindle, Chief of Integrated Services for Aboriginal communities, The Douglas Mental Health University Institute, Montreal, Quebec
Dr Tim Dube (PhD), Assistant Professor Health Professions, University of Sherbrooke, Sherbrooke, Quebec, Canada
24 June
New York, New York USA
Bjorg Pálsdóttir, CEO Training for Health Equity Network: THEnet, New York, USA
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Findings
Community engagement in rural medical training
My Canadian trip commenced with a visit to the Northern Ontario School of Medicine
(NOSM) as part of an international delegation of scholars. The invitation was made by the
Dean of NOSM, Prof Roger Strasser who has been a very important mentor to this project.
He immeasurably strengthened my Canadian itinerary by making introductions to many
eminent persons working on issues related to the rural health workforce and since my return
has continued to make valuable introductions.
Northern Ontario School of Medicine was established in 2005 as a grow-your-own medical
workforce initiative for Northern Ontario funded by the Government of Ontario. It is hosted by
two universities located 1,000km apart: Lakehead University in Thunder Bay and Laurentian
University in Sudbury. NOSM adheres to the World Health Organization’s social
accountability mandate for medical schools, directing its education, research and service
towards addressing the priority health concerns of the communities and region it serves. As
part of its social accountability mandate, NOSM engages with stakeholders at all levels
across Northern Ontario, including teaching hospitals, community physicians4, health
professional clinical teachers, health systems stakeholders and communities. NOSM was
the first medical school in the world to develop a distributed, community-engaged model of
medical education, with its third-year medical students spending their entire academic year
(eight months) living and learning in one of 15 mid-sized communities across Northern
Ontario (termed a longitudinal integrated clerkship). Approximately 90% of NOSM medical
students are from Northern Ontario, 7% are Indigenous and 22% francophone. Around 60%
of NOSM graduates go into family medicine (compared to the Canadian average of 38%)
and most of these end up practicing rurally. NOSM is also involved in allied health education
and delivery of a Dietetic Internship Program, placing dietetics students in 75 sites across
Northern Ontario.
Prof Strasser and I met six months earlier at the Canadian Health Workforce Conference in
Ottawa, Ontario in October 2018 where we both gave oral presentations in the Rural and
Remote Health Workforce Challenges and Opportunities session. Prof Strasser’s
presentation was on The Needs of the Many: NOSM Students’ Experience of Generalism
4 In Canada, the term ‘physician’ describes all medical practitioners holding a professional medical degree. In
Australia, ‘doctor’ is the equivalent term. In Canada, general practitioners (GPs) are called family physicians.
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and Rural Practice. His presentation highlighted NOSM’s social accountability mandate
and its commitment and approaches to community engagement.
Presenters for the Rural and Remote Health Workforce Challenges and Opportunities session at the 2018 Canadian Health Workforce Conference, Ottawa, Ontario, 4 October 2018
From Left : Camille Meub, self, Ruolz Ariste, Martha MacLeod, and Roger Strasser
After the session we discussed how NOSM’s social accountability and community
engagement approaches linked in with my whole-of-person retention improvement
framework and the community and place domain. We agreed to share papers we had
authored and continue to discuss after I returned to Australia. This resulted in several
videoconference meetings and an invitation to join an international delegation5 visiting
NOSM at the Sudbury campus in late April 2019, concluding with NOSM’s annual faculty
development conference, Northern Constellations, on 3–4 May 2019. At this conference, I
attended sessions to strengthen both my understanding of Canadian Indigenous history and
my cultural competency. These included: ‘Blanket exercise: Exploring Canadian and
Indigenous history’; ‘Theatre and conversations with Debajehmujig Storytellers’ and ‘Cultural
humility and the care of Indigenous Peoples’.
5 Scotland – Health Workforce, Leadership and Service Transformation Directorate, NHS Highland, Inverness,
United Kingdom and The University of Dundee;
USA – Texas Christian University and University of Northern Texas Health Science Center School of Medicine;
Australia – University of Queensland Rural Clinical School, Faculty of Medicine;
Canada – McMaster School of Rehabilitation Science.
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My visit to Sudbury included meeting with a range of NOSM faculty, a visit to Manitoulin
Island to meet with the interprofessional team working at the Mindemoya Clinic and a site
visit to the First Nation Shkagamik-Kwe Health Centre operating in Sudbury. I also visited
NOSM’s Thunder Bay campus at Lakehead University to meet with medicine and nursing
faculty and community members to discuss the impact of the NOSM’s community
engagement strategies, including a site visit to Health Co-op, Matawa First Nation
Management.
Northern Constellations 2019, NOSM Faculty Development Conference 3–4 May 2019, Sudbury, Ontario Presenters from the Theatre and Conversations with Debajehmujig Storytellers Workshop
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International Delegation (Scotland, USA, Australia and Canada – see footnote 4 ) visiting NOSM 30 April–4 May, Sudbury, Ontario
Prof Strasser’s support also included an invitation to participate by video conference
(WebEx) in The Making it Work – Remote Rural Workforce Stability Forum in January 2019.
The forum was the final event of the second phase of a collaboration where five participating
countries presented case studies (led by Canada and Sweden, and including Scotland,
Norway and Iceland). The first phase of the collaboration commenced in 2011 and involved
11 northern periphery and arctic region countries funded by the European Union Northern
Periphery Programme. It was aimed at improving recruitment and retention of professionals
working in remote areas (called Recruit & Retain). In Phase 2 (2014–18), called Recruit &
Retain: Making it Work, the five participating countries implemented a suite of interventions
based on the solutions proposed in Phase 1, which were evaluated as case studies.
The Phase 2 collaborators reached a number of conclusions, including:
• rural and remote communities across different countries have more in common with
each other than with their own urban centres;
• short-term workers limit the quality and cultural relevance of services;
• investing in grow-your-own workforce strategies supports workforce development and
improves service stability; and
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• every rural/remote community is unique and needs to involve community
engagement to be successful.
The key output of Phase 2 was the development of a Framework for Remote Rural
Workforce Stability. The Framework describes the necessary elements of a workforce to
ensure the recruitment and retention of the ‘right’ professionals for a sustainable fit-for-
purpose workforce. The Framework consists of nine key strategic elements falling into three
sections:
• Plan (assess population service needs, align service model with population needs);
• Recruit (develop profile of target recruits, emphasise information sharing, community
engagement); and
• Retain (supporting family and spouses, supporting team cohesion, relevant
professional development, training future professionals).
The Framework also outlines five conditions for success: 1) recognition of issues; 2) engage
residents; 3) adequate investment; 4) annual cycle of activities; and 5) monitoring and
evaluation (see figure below).
Figure 5 : Recruit & Retain: Making it Work Framework for Remote Rural Workforce Stability
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Case studies and the Sustainability Plans of the five counties that participated can be read at
https://rrmakingitwork.eu/?page_id=259.
• Canada’s project was undertaken in Nunavut with the support of NOSM staff 6. The
strategies included: a careers camp to encourage youth aspirations in health careers;
facilitating continuing education for physicians; updating the physician recruitment
website; and the creation of a phone app Health Nu to support newcomer workers.
The app includes: information on local history, maps and community information,
communication/language issues, the Nunavut health care model and expectations
including trauma informed practice and an introduction to Inuit culture. In the other
participating countries, interesting initiatives included:
• Sweden’s Come Back To Storuman initiative involving a register maintained by the
local council of all people who have moved out of Storuman Municipality. The register
is used to send newsletters to inform ex residents of what is happening in Storumen
and inviting them to the local festivity, ‘Storumandagarna’, and to participate in
university student information events that are held as part of the festival.
• Scotland's partnership approach in North Scotland (Orkneys and Shetland) between
community and health organisations, working with community members to build
understanding about health workforce challenges and working together to develop a
welcoming plan for candidates and their families visiting the town/region prior to
interview and working with local council to develop resources on the features and
resources available. Development and implement of a buddy support system to
support retention of new health and social care workers.
At the end of my trip I went to New York and met with Bjorg Pálsdóttir the CEO of Training
for Health Equity Network: THEnet (another introduction made by Prof Strasser). THEnet is
an international network of medical education institutions from Africa, Asia, Europe, the
Americas and Australia with a social accountability mandate in underserved rural
communities. The purpose of THEnet is to address health workforce shortages so as to
increase the impact on community health and the development of more equitable health
6 Dr Stephen Tuitt, Dr Francois de Wett and Ms Jennifer Wakegiijig were all actively involved in the
development of these Nunanvut interventions and while I was in Canada I met and interviewed each of them.
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systems. THEnet members share successful education practices, tools and resources.
Their website is a rich resource – https://thenetcommunity.org/our-work/.
New recruitment and retention knowledge emerging from medical education
My interview with Dr Douglas Myhre was significant as emerging evidence from medical
education and medical workforce literature was discussed and the importance of social
processes on rural recruitment and retention were highlighted. Malhi et al.[16] argue that
medical graduates’ choice to practice rurally is complex. They found that while rural
placements during training influence [and longer placements have more impact], rural
practice choice is more likely a result of the effects of ‘accumulated rural experiences over
time’. Such experiences include: rural origin, clinical experiences that support relationship-
based learning (between patient–student, student–teacher and student–community[17]) and
cultural and personal satisfaction with rural living/lifestyle. Myhre et al.’s scoping study on the
determinants of urban origin students choosing rural practice identified that physicians who
are retained in a rural practice for a longer duration are those whose spouse/partner is able
to find work in a rural community[18]. Myroniuk et al.’s[19] study investigating the recruitment
and retention of physicians in rural Alberta, from both the physicians’ and spouses’
perspectives, found that spouses were a positive influence. The study found that the
decision to relocate to a rural community was mutual and couples commonly assessed a
prospective town for whether it was a good place to raise a family (considering such factors
as safety, quality of education system, access to recreational activities and proximity to an
urban centre). The key retention issue for physicians was whether the town was able to
provide their spouse with employment and the social impact of the rural move on their
spouses (i.e. whether their spouse had been able to successfully integrate into the
community). International physicians compared to Canadian physicians and their spouses
experienced greater difficulties integrating into a rural community due to cultural differences.
Given the important influence of spouses in rural medical practice recruitment and retention,
the study made recommendations to better support spouses. These included: 1)
partnerships with private industry to assist with identifying and accessing opportunities for
spousal employment; and 2) the development of a centralised database for medical practice
opportunities with links to potential jobs for spouses, schools, recreational information and
community demographics.
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Strategies for encouraging welcoming and inclusive rural communities to support recruitment and retention
In relation to improving the social connection of health workers in rural settings, the most
relevant meeting I had at NOSM was with Dr Sarah Newberry who, as well as being a family
physician involved in the delivery of NOSM’s integrated clerkship program, was the co-chair
of the recently established Northern Ontario Physician Taskforce. The taskforce was
established after Summit North 2018, which was held to address the significant physician
recruitment and retention challenges still being experienced in Northern Ontario despite ten
years of NOSM graduates. The summit was hosted by NOSM, HealthForceOntario and the
Northeast and Northwest Local Health Integration Networks. It was held on 24 January 2018
and 125 stakeholders attended. The summit’s objectives were threefold:
1) develop an accurate shared understanding on health human resource needs;
2) explore innovative models that support a flourishing physician workforce; and
3) commit to strategies to address physician human resources needs.
Building on recommendations made at the summit, the taskforce subsequently created the
Northern Physician Resources Action Plan. The plan identified five action areas: 1) creating
healthy and resilient physicians and teams; 2) ensuring welcoming communities; 3) training
and supporting skilled, competent rural generalist physicians; 4) building local and regional
support networks; and 5) ensuring supportive infrastructure. With respect to ‘ensuring
welcoming communities,’ five recommendations were made:
1) Create education for communities regarding health human resources.
2) Develop engagement and orientation session for each new health worker arriving in
a community.
3) Create ways for communities to collaborate rather than compete, (e.g. ‘join up’
recruiters and opportunities for physicians to find ‘good fit’ with communities).
4) Ensure continuing development in human resources, including coaching and
mentoring for recruitment.
5) Leverage the experience of students and medical residents in communities –
identifying what made them feel welcome (unwelcome).
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Additional health workforce challenges in remote settings and emerging solutions
I was invited to Iqaluit as a visiting scholar by Ms Charleen Austen, Assistant Deputy of
Health Operations, Department of Health, Government of Nunavut. The main purpose of the
visit was to make a presentation to Department of Health staff and invited guests. The trip
also included meeting with senior medical and nursing staff at the Iqaluit hospital. The
invitation came out of connections made with Government of Nunavut, Department of Health
staff at the Canadian Health Workforce Conference in Ottawa (3–5 October 2018). As part of
the conference, I attended a pre-conference workshop on a grow-your-own workforce
strategy – the Educational Upgrade Program (EUP) developed by Department of Health,
Government of Nunavut to support the educational and career advancement of Inuit staff.
The workshop presenters were Victor Akande (Executive Director of Health Operations –
and the EUP designer), and Timothy Fawehinmi (EUP Coordinator). The EUP was designed
to be undertaken locally in Nunavut Territory and uses a laddering approach, enabling Inuit
staff to progress from Grade 12 to College Certificate to Diploma to Bachelor’s degree in
Health Sciences or related disciplines. EUP participants are able to use 7.5 hours of their
work week for academic study and are provided with a laptop, internet access and textbooks
and their tuition costs are covered. Academic tutors are engaged to adapt and translate the
knowledge from the college/university program, using Nunavut-relevant contexts to help
foster students’ understanding; this support is provided both one-on-one and in group
tutorials.
At the same conference, I gave a presentation, as part of the Gender, Equity and Diversity
Panel, on Factors impacting the job satisfaction of Aboriginal mental health workers working
in public sector community mental health in rural and remote New South Wales, Australia.
Victor Akande, Timothy Fawhinmi and I discussed the many shared challenges between
Inuit Canadians and Indigenous Australians and the similar approaches both programs (the
EUP and the NSW Mental Health Workforce Training Program for Aboriginal People) were
using for trying to develop a home-grown workforce. In particular, both programs were
designed to ensure that the training was available locally, was culturally appropriate, and
that it addressed barriers to learning. During my visit to Nunavut, I met with Timothy
Fawehinmi to discuss the EUP in more detail. He advised that the first cohort of 11 students
had just graduated at a cost of approximately C$500K, with the most significant cost being
academic tutors at C$150K.
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The presentation I made to Department of Health staff in Iqaluit was entitled: Retention of
healthcare professionals in rural Australia: Current research and implications for Canada. It
was attended by 11 Government of Nunavut, Department of Health staff.
Department of Health, Government of Nunavut, staff attendees to my presentation in May 2019, in Iqaluit.
From left: Timothy Fawehinmi, Ruby Brown, self, Francois de Wet, Madeleine Cole, Patrick Foucault, Amber Miners; Charleen Austen, Tenzin Lama, Jessica Barrett-Ives.
After the presentation I met with Charleen Austen and we discussed the challenges of
leading health service transformation in an increasingly complex environment that is non-
linear, has multiple interdependencies and no single locus of control. Ms Austen saw
synergies between my whole-of-person retention improvement approach and emerging
research in developmental psychology of adults arguing that people construct their own
reality and interact with the world based on the epistemology (or mindset) of their stage of
personal development. Petrie and Swanson argue that adults hold ingrained assumptions
and generalisations that influence how they understand the world and take action in it[20].
They suggest that the skills needed for leading large scale change require significant
cognitive and interpersonal development of the leader to support vertical development (i.e.
how we know), not just what we know. They describe ‘transformational leaders’ as people
who challenge mental models, unite stakeholders behind a shared vision, cross
organisational boundaries and make changes that are inherently sustainable[20].
I also visited the Qikiqtani General Hospital in Iqaluit. The hospital is a 35-bed acute care
facility providing hospital services to the population of 16,000 people, including 12 Inuit
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communities living in the Baffin Region of Nunavut, covering approximately one million
square kilometres. I met with Dr Stephen Tuitt (MD), Territorial Director – Medical Affairs, Dr
Francois de Wet (MD), Territorial Chief of Staff – Medical Affairs, and Ms Jennifer Pearce,
Clinical Nurse Educator to discuss workforce challenges and approaches.
Drs de Wet and Tuitt discussed the Department of Health’s strategy for recruiting physicians.
The Department of Health operates a Medical Affairs Division with eight dedicated staff, to
deal with all aspects of physician recruitment – billing, travel, accommodation, etc. The
Division has been applying its expertise on what attracts physicians (the environmental
experience, the culture, the physician group and know-how to care for them – including
providing high quality housing, which is free for locums and subsidised for full-time
physicians). To recruit physicians, the Department of Health uses three approaches: 1)
targeting residents who have undertaken rotations in Nunavut; 2) attending physician
conferences that attract over 1,000 delegates; and 3) using a dedicated physician
recruitment website launched in October 2018 https://www.nunavut-physicians.gov.nu.ca. In
the last two years the focus has moved from attracting full-time physicians (there are
currently two permanent physicians) to attracting long-term locum physicians. Long-term
locums commit in advance to 75/105 days a year, work a minimum of 15 days per locum
visit, and receive a commitment bonus of C$20/30K at the end of each year of service. Since
the website was launched, they have been receiving approximately 15 enquiries a week and
about one third of these are proving to be solid leads. Dr Tuitt now anticipates that in the
next six months there will be no physician vacancies in Nunavut. He attributes this success
to shifting the focus to longer-term locums and, because locums are recruited as contractors
(not employees), there is greater flexibility around employment arrangements.
In contrast, Ms Pearce spoke of the increasing challenge to attract and retain a nursing
workforce in Nunavut’s hospital and community settings. The collective agreement that
registers nurses (RNs) work under in Nunavut was discussed as having a negative impact
on nursing recruitment. In Nunavut, RNs are part of a general union that includes a broad
range of worker groups (e.g. admin workers, plumbers, allied health), and among these, RNs
are the highest paid. Because nurses are under a collective agreement, there is no scope to
be innovative around nurses’ employment arrangements – such as offering more
professional development or incentives. Under this collective agreement, the only incentive
that can be offered is a C$5K bonus payable on hire and requiring no minimum period of
work. Ms Pearce stated that in the last three years, six new RNs had come to Iqaluit
hospital, been paid their bonus and then left within six weeks of hire. Before the current
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collective agreement, the bonus system operating included three payments being paid
after working a set period.
The Department of Health’s human resources department is responsible for recruiting
ongoing nursing positions and the recruitment process (job posting, interview, offer) and was
described as being very slow, commonly resulting in the hospital losing ‘amazing’
candidates. Now nursing staff in Nunavut are being recruited through the Casual Staffing
Action (CSA), which offers fixed term contracts that cover flights, pay a subsidised rent and
provide accommodation in Department of Health-provided transient units. The employment
arrangements under the CSA are far more lucrative than being employed as a permanent
staff member. Ms Perace stated that the only permanent nursing staff now are long-term
staff members who have all chosen to stay for personal reasons (e.g. children at school or
own a home).
I also met with Ms Yvonne Hindle, responsible for coordinating mental health services for the
Cree communities in the Nunavik region, in northern Quebec. This includes overseeing the
fly-in-fly-out psychiatrists and providing mental health educational services to local nurses.
We discussed the significant health workforce recruitment and retention challenges in
Nunavuk and the creation of community wellness liaison officers as a grow-your-own
workforce initiative. Ms Hindle made email introductions to staff working in Nunavuk who
may be interested in participating in future rural health retention research and extended an
invitation to visit Nunavuk on future trips I may make to Canada.
Training in place – building connection with communities
Many people interviewed were actively involved in the development and/or administration of
health student placement programs (Prof Roger Strasser, Ms Jennifer Turcotte-Russak, Mr
Robert Barnett, Dr Glenna Knutson, Assoc Prof Karen Poole, Dr Sarah Strasser, Dr Joanna
Pierce, Dr Paul Winwood, Dr Maggie Watt and Dr Aaron Johnston). Most described rural
placements as being work intensive for everyone involved but thought they were effective,
especially for students participating in longitudinal placements. Their main impact was in
fostering the development of a student’s professional identity and accountability as well as
building a sense of understanding and belonging by offering an opportunity to be part of a
rural community and a rural health workplace. As one NOSM student described the benefits
they had derived from an immersive rural experience: You don’t know it until you live it.
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Community engagement in the longitudinal integrated community clerkships (LICC) for
medical students involved them working closely with local family physicians (in a preceptor
role), ongoing involvement with patients, and living in rural communities and engaging in
cultural and local leisure activities. My interview with Dr Tim Dube was significant in
highlighting recent research he had undertaken on the importance of community for social
connection for medical students undertaking LICCs [21]. The broader community was
identified as being essential for the development of a sense of belonging. This support was
provided in different ways: at the beginning by welcoming and helping orientate to the
workplace and the social setting, and by community members enthusiastically agreeing to
students’ participating in their health care, strengthening both the learning experience and
understanding of social connections in the community[21].
Sense of place – building understanding of how rural connection happens As part of developing my Churchill Fellowship application, I approached A/Prof Judy
Gillespie at the University of British Columbia (UBC). A/Prof Gillespie is a tenured staff
member at UBC’s Faculty of Health and Social Development in the School of Social Work.
Her research interests include: the role of place in wellbeing, the interactions of person and
place, and the ways in which professional practice is shaped by place. I first came across
A/Prof Gillespie’s work as a PhD candidate. Two journal articles [22, 23] she had authored
strongly supported my findings on the key influences on turnover of rural-based health
professionals. We had both separately found that personal satisfaction significantly differed
between locals and newcomer workers. A/Prof Gillespie was not only very interested in my
rural health retention research, but also extremely supportive in helping develop my
Canadian itinerary for my Churchill Fellowship application.
In October 2018, as part of my position as a Research Fellow at University of Melbourne, I
travelled to Canada to present at two research conferences: the Canadian Health Workforce
Conference, Ottawa, Quebec from 3–5 October, and Canadian Rural Revitalization
Foundation – Health and Shared Prosperity Conference, Saskatoon, Saskatchewan, from
10–12 October. As part of this trip, A/Prof Gillespie invited me to visit the University of British
Columbia’s Okawangan’s Kelowna campus (13–17 October 2018) as a visiting scholar. The
purpose of the visit was for A/Prof Gillespie and I to start planning for my Churchill
Fellowship visit in May–June 2019 and to explore the feasibility of forming a
Canadian/Australian research partnership, including identifying potential funding
opportunities. During this visit I made two presentations on my research: one to the public
and another to faculty members of UBC’s Institute for Community Engaged Research. To
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support partnership development, and to establish a track record for future funding, a co-
authored peer-reviewed journal article was written in late 2018 and published in early
2019[12].
The purpose of visiting A/Prof Gillespie as part of my Churchill Fellowship trip was to further
progress the development of the research partnership to be led by myself and A/Prof
Gillespie. During my ten-day visit, A/Prof Gillespie and I met most days. We determined that
the aim of the research partnership was to progress understanding of the role sense of place
has in the retention of professionals in the health and social service sectors working in rural
settings.
Self and Judy Gillespie 6 June 2019, Kelowna, British Columbia
We developed a research plan covering the next 5–7 years commencing in 2020. The
research plan covers three research phases and particular research question(s) were
formulated for each research phase (see Table 1 below).
Table 1: Australian–Canadian research partnership: research phases and questions
Research Phase Research Questions
Phase 1 – Insight development What are the elements of ‘sense of place’ that influence the retention of professionals working in the health and social service public sectors in different rural settings in Australia and Canada?
Phase 2 – Partnership development
How can we engage in collaborative research in Australia and Canada that utilises elements of ‘sense of place’ to:
o positively impact retention strategies for development and implementation by public service institutions operating in rural settings?
o positively impact retention strategies for development and implementation by rural communities?
o strengthen the curriculum to better prepare professionals for practice in rural settings?
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Research Phase Research Questions
Phase 3 – Partnership implementation
What elements of ‘sense of place’ strengthen preparation for and positively impact retention in rural settings? (positive change) What elements of ‘sense of place’ have utility for curriculum development, workforce planning, and community development?
The proposed ‘core’ research team for the first phase is myself, A/Prof Gillespie (UBC) and
Dr Malatzky (Queensland University of Technology). We are currently working on a journal
article that considers the utility of conceptualisations of place and belonging in workforce
retention strategies and plan to submit this article to a high quality peer-reviewed
international journal in September 2019. Grant funding opportunities to support Phase 1 are
also being actively pursued by research team members in their respective institutions and
jurisdictions. In August 2019, we were invited to contribute an article to the Journal of
Sociology for its Special Issue: Imagining rural and rural sociology futures in times of
uncertainty and possibility: Progressing a transformative research agenda. The title of our
co-authored paper is Person, place, and community in Canada and Australia: Transferability
and adaptation in professional retention in rural and remote localities. The research team
continues to meet monthly via videoconference.
The planned collaborative research will involve newcomer workers and members of rural
communities from Australia and Canada and will likely be qualitative. The use of a
participatory action research methodology, as is being currently used for the whole-of-person
rural retention improvement trial in Victoria, was discussed as a potentially useful
methodological approach. While I was visiting Canada, the University of Alberta’s
International Institute for Qualitative Methodology was running its annual Thinking
Qualitatively Workshop Series, and this provided an opportunity to strengthen my skills in
participatory action research. I attended two sessions: ‘The Photovoice: What it is and how
to do it’ (1/2 day) and ‘Participatory Video: Introduction and Experimentation’ (1 day). A very
useful connection was made with the presenter of the photovoice workshop, Adjunct
Professor Linda Liebenberg, who has undertaken extensive research on sense of place and
belonging among Indigenous youth in rural Canadian communities using a participatory
action research methodology.
I also was invited by Professor Martha Macleod from the University of Northern British
Columbia (UNBC), (who I also met at the Canadian Health Workforce Conference in Ottawa
in October 2018 – see photo on page 10) to visit the Prince George campus and present to
researchers involved in the Nursing Practice in Rural and Remote Canada II national
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research project on my whole-of-person retention research and, in particular, to discuss
the findings from my recently published social determinants of retention paper and its
relevance for the Canadian context. I was also invited be a guest lecturer for the UNBC’s
Health Research Institute. The presentation was attended by staff from the UNBC and the
Northern Health Authority. Professor Macleod has subsequently advised that the role and
career building domain of my whole-of-person retention improvement framework was of
particular interest to the Northern Health Authority staff and she is currently working with
them on ways of addressing the challenge of providing career development opportunities to
nurses working in sole-positions in small rural communities while also continuing to retain
them.
Recruiters – facilitating community connection
‘Physician Recruiters’ are commonplace all across rural Canada. Most commonly, recruiters
are employed by government departments or government agencies such as Health Match
BC https://www.healthmatchbc.org/ to address the health workforce needs of local hospitals
and/or family physician clinics operating in rural regions. In the province of Ontario,
HealthForce Ontario http://www.healthforceontario.ca (part of the Ministry of Health and
Ministry for Long-Term Care) helps support rural remote northern health employers and
communities to recruit and retain health professionals by offering a range of programs
especially targeting family physicians. Health professionals (and their spouses) who are
considering working in more remote communities and wanting to visit the community to
assess the practice and living opportunities are eligible to have their travel and
accommodation costs reimbursed (see
http://www.health.gov.on.ca/en/pro/programs/northernhealth/cav.aspx). HealthForce Ontario also
provides resources written by recruiters for recruiters under the title Recruitment essentials
http://www.healthforceontario.ca/en/Home/All_Programs/Physician_Recruitment_for_Communities/Re
cruitment_Essentials. Some examples of the resources available are: Succession Planning for
Health-Care Organizations and Recruiters; Customer Relationship Management; Physician
Onboarding.
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Case Study –– Recruiter and Community Connector Model, Marathon, Ontario Background Marathon is a township of approx. 3,200 people located in Thunder Bay District, Ontario, situated on the north shore of Lake Superior, 300km from the capital. The Ojibways of Pic River and Pic Mobert First Nation are situated nearby and comprise about 950 people living on reserve. Marathon has a relatively young demographic compared to most rural Canadian towns, with the average age being 46 years. The economy of Marathon is heavily reliant on the resource sector (gold mining and paper and pulp milling) and currently 550 residents are employed at the two gold mines operated by Barrack Gold. The town’s primary health care services are delivered by the Marathon Family Health Team (MFHT). The MFHT is a multidisciplinary team currently including: family physicians (9), physician assistant (1), nurse practitioner (1), registered nurses (2), registered practice nurses (2), allied health professionals (dietician, social worker), community health promotions coordinator (1), epidemiologist (1), and IT technician (1). The town has a small hospital, Wilson Memorial General Hospital, run by the MFHT family physicians. The hospital has acute (9) and chronic care (12) beds and obstetrics as well as a 24-hour emergency department. There are physician shortages everywhere in Northern Ontario.
The Problem In 2010, three long-serving MFHT family physicians announced they would be leaving the Marathon community, two in order to live closer to their children who were about to commence college and the other to move closer to family and friends living in a larger community. Facing a major increase in their workloads, the four remaining physicians decided to engage external support to help with recruiting locums short-term and finding replacement family physicians in the medium-term. To help fund the ‘recruiter’ position, the town’s largest employer, Barrack Gold, the Town of Marathon (local council) and the hospital were approached and agreed, in the interests of economic development, to co-fund the position with MFHT. At the same time, the Marathon Physician Recruitment and Retention Committee (MPRRC) was established with representatives from the MFHT (Physicians and Executive Director), the Town of Marathon (CEO), the hospital (Administrator Officer) and Pic River First Nation and others.
Solution A job description was developed, outlining that the recruiter was responsible for the ‘administration and coordination of the overall physician recruitment efforts for the community of Marathon’. The position was created as a contractor role for 960 hrs over 12 mths (annual salary cost approx. C$35K, and a small amount of discretionary funding C$5–10K) with the position reporting to the MPRRC on a set of deliverables. The essential selection criteria were qualifications and experience in marketing/communications/human resources and the preferred criteria included: experience working with community boards/committees, understanding of the health environment and the special issues facing Marathon. The position was advertised locally and was filled by Brett Redden – who is still the incumbent ten years later. Brett was able to structure the position to work with his other employment (golf pro May–October), so he works most of the hours from November–April using the office provided by MFHT, and works just a few hours over the summer months to meet newly-arriving students, locums and residents. His position has expanded over the decade to ‘Recruitment and Retention Coordinator’ and moved beyond just physicians to include allied health professionals and he also has responsibility for liaison with the NOSM medical students. Most family physician recruitment has come from Toronto-based medical schools at Ottawa University (20%) and McMaster University (80%).
Impact Brett identifies the most important things for successful recruitment and retention as being:
• Seeing the role as a customer-service, starting from the very first interaction.
• The need for a positive working environment that has a professional supportive health team and strong social dynamic that functions inside and outside of the workplace.
• Understanding and addressing the needs of the whole family. If this involves spousal employment, Brett works with government employment agencies and other local entities that support job seekers or directly with local businesses to help locate a job. Employment in Marathon is limited and can take
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some time to secure – often a year or two. Sometimes employment cannot be found for the spouse, and then the spouse is either OK with that or, if not, then the couple usually decides to move on to somewhere where they can both find work. However, this does not happen very often, as most of the newly-arrived health professionals to Marathon who are a couple are at the early years of the family-life stage and either about to start a family or already have young children, and so the other partner often chooses to be a stay-at-home parent. Most newly-arrived health professionals moving to Marathon are single
• Having a dedicated person to assist new arrivals with developing ‘social bonds’ in the community. This involves Brett meeting each new arrival (and any family members) one-on-one and then facilitating in-line with the new arrivals’ interests and appropriate to their life stage – especially local recreational activities and invitations to events and activities in the local community. This support continues until the new arrival has formed a local social network.
• Having a positive community spirit. Have a group of local people that will always lend out very expensive equipment to facilitate recreational activities – e.g. lending skidoo, quad bikes. This has built over the years as the community has seen the results of having the recruiter position.
• With improved family physician staffing, supporting the development of a medical workforce pipeline by making MFHT a teaching site assessable for NOSM.
Brett identifies his greatest recruitment and retention successes as being:
• Supporting people who first come as medical residents, then return as locums and later become full-time MFHT family physicians. In one case, two single physicians met in Marathon, got married and have stayed on.
• Recruiting the Physician Assistant (PA) role and at a PA conference speaking with a newly graduated student who was interested in the position and the Marathon community but needed there to be employment opportunities in education for her spouse. In the first few months of arriving, Brett worked with the local employment agency to support the spouse to gain a position at one of the local schools. The couple stayed on.
• The long-term retention of family physicians. Seven of current nine family physicians are ‘completely committed’ to living in Marathon, including a couple with over 20 years retention, and others for 19 years, 15 years, and 6 years respectively. Most of the family physicians that have been recruited have gone on to settle down and have their families in Marathon. The two family physicians who are currently undecided are younger, still single, and just getting started in their careers.
The things about the role that make it successful:
• The position is very broad in scope; it’s about showcasing the community, so hours need to be super flexible, it’s not a 9–5 type job!
• Senior executives from the participating organisations/groups are actively involved in the management of the role.
• The position needs to be community supported through local council and be funded (both cash and in-kind).
• The position needs to be seen by the community members as a ‘community asset’.
• The incumbent needs to be a non-local and demonstrate that they have successfully made the move from a bigger place to join this community.
• The incumbent needs to have the ability to develop and utilise local networks to support activities.
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Photo Collage
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Discussion
This section assesses the importance of the findings from my Churchill Fellowship and
identifies and evaluates the project’s achievements. This is done under the following section
headings: similarities and differences, the expected and unexpected, best practice
highlights, and value of the experience and extent of achievements.
Similarities and Differences
Canada was selected as the focus of my project on the grounds that any identified
‘successful’ approaches would likely be replicable given Australia and Canada’s similar
contextual characteristics (large land masses, population size and make-up and distribution,
colonial histories, Commonwealth nations, secondary and tertiary education systems and
health training pathways and universal public health service systems). This proved a correct
assumption: I found Canada and Australia very similar in many ways, and after working
through terminology differences (see footnote 3) and opposite climate challenges, I believe
the chance of successful replication of innovative approaches is very high. As the Recruit &
Retain: Making it Work study stated, ‘rural and remote communities across different
countries have more in common with each other than with their own urban centres’.
The Expected and Unexpected
As expected, I found that rural health workforce turnover and shortages were also a very
significant problem in Canada. However, I found significant differences in the scale and
approach being taken in Canada to address the issue. In Australia, for the last 20 years the
rural health workforce has been a priority policy issue of the Australian Government.
National policy efforts have involved increasing the number of government-funded university
training places for health students, setting quotas in university health courses for students
from rural backgrounds, and offering financial incentives and supports to encourage qualified
health professionals to ‘go rural’[4]. In Canada, the issue is managed at the provincial or
territory level with varying degrees of resourcing and a broad range of approaches.
As part of the Australian Government’s rural health policy agenda, it supports rural health
workforce research and innovation through its funding of 16 university Departments of Rural
Health (UDRH). These UDRHs operate across all Australia’s states and territories and
collaborate through the operation of a national peak body – the Australian Rural Health
Education Network. ‘UDRHs are committed to ensuring that the health workforce needs of
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rural and remote areas are addressed by national strategies’ (https://arhen.org.au/about-
us/). The operation of UDRHs has helped prioritise research on Australia’s rural health
workforce, resulting in many peer-reviewed publications. In Canada there is arguably a far
less coordinated approach to rural health workforce and far less investment in research. It
was fairly common in my meetings in Canada for interviewees to say they looked to
Australian research for guidance on successful approaches to addressing rural health
workforce issues. I think this partly explains why I found only a few examples in Canada of
successful community-engagement approaches for attracting and supporting ‘newcomer’
health workers. However, my discovery of the Recruiter and Community Connector Model in
Marathon, Ontario and impressive record in attracting, recruiting and retaining health
workers to a small rural town was one of the highlights of the trip. And while Canada offered
only a few examples of successful community engaged approaches, I was introduced to
other examples of innovative community engagement approaches aimed at attracting and
retaining health workers in far northern countries through my exposure to the country case
studies in the Recruit & Retain: Making it Work study.
Before my trip, my rural health workforce research had solely been focussed on the
experiences of allied health and nursing workers (and students). However, many of the
introductions made by Professor Strasser were to people involved in rural medical education
and rural medical workforce development. Through interviewing many medical
practitioners/teachers/preceptors, my rural health workforce knowledge now includes
medical workforce and the medical workforce research also emphasising the role of
community and place and the importance of social connection and belonging for recruiting
and retaining rural doctors.
Best Practice Highlights
As mentioned above, the standout best practice highlight was the Recruiter and Community
Connector Model in Marathon, Ontario (outlined in the case study). In Australia, while there
are Federally funded rural health workforce agencies operating in each state, their focus is
primarily on recruitment and addressing workforce gaps and shortages. As far as I am
aware, Australia does not have similar ‘community-based’ positions. The Recruiter and
Community Connector Model is also unique in that it is concerned with addressing all stages
of the rural health workforce pipeline7 from attraction to recruitment and retention and
providing individually tailored support to newcomers (and their families) to assist them to
7 See Appendix 2
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successfully settle in and make meaningful connections in the local community. The
scope of the position demands that the incumbent understands the unique attractions and
detractions of the town/region so he/she is able to accurately promote its positive features
and manage expectations regarding the deficits and likely challenges of working/living in the
rural town. The models shared funding and governance structures between the medical
centre, local council, and the major employer in Marathon town (and their continued funding
over the last 13 years) demonstrates that the Marathon community understands and values
the economic and community development benefits of having a flourishing health workforce.
The successful recruitment and high retention outcomes achieved over the last 13 years for
a relatively modest annual investment (A$50K approx.) suggest that the model is efficient
compared to the known significant direct and indirect costs of high turnover and unfilled
health positions in rural towns.
The framework developed from the Recruit & Retain: Making it Work study confirms the
validity of my whole-of-person rural retention improvement approach. Both frameworks
identify the importance of community engagement and providing social supports in the
community and workplaces. Some of the community engaged approaches outlined in the
case studies may also be a useful starting point for Australian rural communities to develop
their own town-specific strategies to attract, recruit and retain a health workforce. Of
particular note is:
• Nunavut’s phone app, Health Nu, to support newcomer workers,
• Sweden’s Come Back To Storuman initiative to track and encourage ex-residents to
consider, and
• Scotland's community engaged approach (involving the local health service,
community and local council) in recruitment and retention activities and development
of town-specific resources aimed to attract workers and assist newcomers, and the
buddy support program implemented in the health service to support social
connection of newcomer workers in the workplace.
Another best practice highlight was the grow-your-own workforce initiative – the Educational
Upgrade Program being implemented by the Nunavut Government, Department of Health to
support the career aspirations of its local Indigenous workforce. The model has relevance for
the development of similar programs in rural, and especially remote, Australia. In particular,
the provision of academic tutors to make the curriculum context-relevant and providing IT
resources ongoingly – namely laptops and internet access to support life-long learning.
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Value of the experience
My Churchill Fellowship provided me with the opportunity to undertake an environmental
scan of what was happening in Canada, as well as in other rural high income countries, in
terms of approaches being implemented in rural communities aimed at supporting
‘newcomer’ health workers to develop social connections and a sense of belonging. Overall,
as discussed above, while a community engagement approach has been identified in the
research as being critical for attracting, recruiting and retaining a rural health workforce, it is
still a relatively new finding and so, not surprisingly, there are very few examples of
successful approaches available. A notable exception is the Recruiter and Community
Connector Model. The Recruit & Retain: Making it Work strategies, while promising, have
only been fairly recently developed and trialled and longitudinal data is needed to assess
their effectiveness in terms of improving social connection and belonging as well as their
overall impact on retention.
To encourage innovation and support the development of more effective community-based
rural retention strategies, more sociologically-informed research is also urgently needed. A
very significant achievement of my Churchill Fellowship was to establish an Australian–
Canadian research partnership to progress understanding on the role sense of place has in
the retention of professionals in health and social service government sectors working in
rural areas of high income countries that are large land masses and sparsely populated.
Key achievements The aim of my Churchill Fellowship was to investigate successful, innovative approaches for
attracting, recruiting and retaining health workers in regional, rural and remote areas and to
use this knowledge to strengthen my whole-of-person rural retention improvement
framework. The Canadian trip had two objectives:
• to increase knowledge of successful approaches being used in rural Canada to
actively support ‘newcomer’ health workers to improve their social connection and
sense of belonging; and
• to increase my knowledge of innovative ‘grow-your-own’ workforce strategies,
especially those focused on Indigenous workers.
The key achievements of my Churchill Fellowship are the:
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• establishment of an Australian–Canadian research partnership to progress
understanding of the role sense of place has in attracting and retaining health
professionals to work and live in rural settings;
• identification of the Recruiter and Community Connector Model successfully
operating in Marathon Ontario;
• identification of the grow-your-own workforce strategy – the Educational Upgrade
Program being implemented by the Department of Health, Government of Nunavut to
support the educational and career advancement of Indigenous staff;
• being linked into an international network of people working in universities, rural
health services, communities and government departments involved in strengthening
understanding of community engaged approaches to attracting rural health
professionals.
Recommendations and Dissemination Plan
To help address the ‘wicked’ problem of rural health workforce shortages and high turnover,
as well as the need for investing in a pipeline approach, strengthened community
engagement is urgently required to attract, recruit and retain health professionals.
Community involvement in rural health recruitment and retention requires a whole-of-
community approach, and the need for co-designed strategies that are evidence-informed,
placed-based and contextually relevant. My rural health workforce research and the whole-
of-person rural retention improvement framework emphasises the importance of newcomer
health workers successfully settling in and developing a sense of belonging in the rural
communities in which they live and work. I consider grow-your-own workforce initiatives to
be part of a community engaged approach to addressing rural health workforce challenges.
To strengthen this community engaged approach for addressing rural health workforce
issues, there is an urgent need for:
• collaboration among rural and remote communities across different countries to
strengthen the evidence-base;
• education and strengthened understanding among key stakeholders in Australia on
the importance of, and urgent need for, community engagement in addressing rural
health workforce issues; and
• trialling innovative community-based models aimed at strengthening and stabilising
the rural health workforce in regional, rural and remote communities across Australia.
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Collaboration among rural and remote communities across different countries to
strengthen the evidence-base
1) Through the development of the established Australian–Canadian partnership: a)
strengthen understanding of the role sense of place has in the retention of
professionals working in health and social service government sectors in rural
settings; and b) seek research funding to undertake mirror research in each country
to identify what elements of sense of place have utility for curriculum development,
workforce planning, and community development.
2) Undertake an environmental scan in Australia to identify current/previous community
engaged approaches/models aimed at addressing rural health and social service
workforce issues, complete a desk-based evaluation to assess their effectiveness
and efficiency, and write-up and share any successful case studies (see
Recommendation 9).
3) Strengthen links made with rural and remote communities across different countries
involved in community engaged approaches to recruitment and retention, particularly
those northern countries involved in the Recruit & Retain – Making it work study, with
the aim to establish an information sharing network of innovative approaches being
trialled, evaluation results and case studies of successful approaches.
Education and strengthened understanding among key stakeholders in Australia
on the importance of, and urgent need for, community engagement in addressing
rural health workforce issues
4) Seek opportunities to run participatory workshops with rural communities to present
the whole-of-person retention improvement framework for the purpose of building
understanding of the need for a community engaged approach for addressing rural
health workforce issues and undertaking group work to develop context-informed
community engaged strategies to inform the local town or region’s health workforce
development planning.
5) Seek opportunities to build understanding of the Executive and Human Resources
personnel working in rural health services and personnel from relevant Government
departments on the evidence for adopting a community engaged approach to
effectively address rural health workforce issues, and to promote the whole-of-person
retention improvement framework and the recruiter and community connector model
(through presentations or keynote addresses at national conferences, media
interviews, and in peer-reviewed publications).
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6) Seek opportunities to meet with relevant Australian Government Ministers (e.g.
Health, Social Services, Regional Development, Indigenous Affairs) and key
government appointments (e.g. Rural Health, National Rural Health Commissioner)
to build understanding of the needs case for a community engaged approach for
addressing rural and remote health workforce shortages and turnover, and lobbying
for funding to support a longitudinal trial of the Recruiter and Community Connector
Model in regional, rural and remote communities across Australia.
Trialling, innovative community-based models aimed at strengthening and
stabilising rural health workforce, in regional, rural and remote communities
across Australia.
7) Identify rural and remote communities in Australia interested in trialling the Recruiter
and Community Connector Model as a whole-of-community with major employers
including health services and local councils willing to make a financial commitment to
funding the Community Connector position for a minimum of five years.
8) Conduct a longitudinal evaluation study (for a minimum of seven years) on the rural
communities involved in trialling the Recruiter and Community Connector Model. The
evaluation will involve: collecting baseline data on current workforce shortages,
turnover and retention rates; implementing tools and measures to assess
effectiveness and efficiency of the model; and collecting qualitative data to write-up
and share successful case studies and help build the evidence base.
9) Create a website on community engaged approaches addressing rural health
workforce issues to provide resources including national and international case
studies, examples of resources developed, publications and presentations of the
research evidence etc. for use by the rural communities involved in trialling the
Recruiter and Community Connector Model and other interested stakeholders,
including other countries participating in the information sharing network (see
Recommendation 3).
10) Conduct an initial and annual conference for the duration of the trial to encourage
innovation and success and support through networking opportunities to the rural
communities involved in trialling the Recruiter and Community Connector Model. The
conferences would include: international and national keynote speakers,
presentations on evidenced-informed best practice approaches and sharing by the
communities on their successes and failures.
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Additional dissemination activities planned
Recommendations 4–6 specifically outline the key audiences I am targeting. The
recommendations also outline the strategies for dissemination. In addition to implementing
these strategies, my dissemination plan includes:
Sharing this report with:
• Rural communities interested in developing whole-of-community solutions to
addressing health workforce shortages
• The Ministers for Health, Social Services, Indigenous Affairs and Regional
Development in the Australian Government and all state and territory
governments
• The Rural Health Commissioner
• The rural workforce agencies and other government departments and programs
operating in all states and territories concerned with addressing rural health
workforce issues (e.g. Boosting the Local Care Workforce Program – Australian
Government, Growing Regional Opportunities for Work – Victorian Government)
• Australian academics, and those from other countries, who are known for their
interest in, and research on, rural health workforce recruitment and retention
issues and/or rural community engagement approaches.
Distributing the Report through my Facebook, LinkedIn and Twitter accounts.
Writing an on-line short opinion piece linking to the Report for The Conversation
http://theconversation.com/au; and/or The University of Melbourne’s equivalent Pursuit
https://pursuit.unimelb.edu.au and/or Croakey – social journalism for health
https://croakey.org.
Dissemination activities undertaken since returning Since returning in early July 2019, I have been able to undertake some dissemination
activities to progress implementation of the recommendations made. This includes:
Recommendation 3: Invitation (September 2019) to participate in research
commissioned by the Scottish Government to undertake an international review of
models of multi-disciplinary teams working in rural primary care. The invitation was a
result of connections made with the Scottish delegates involved in the Recruit &
Retain, Making it Work study.
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Recommendation 4: Engaged by Latrobe Valley Authority (funded by the
Victorian Government) to develop and run (in August 2019) three, three-hour
community participatory workshops across Gippsland, Victoria (Wonthagggi,
Tralalgon and Bairnsdale) entitled ‘Whole-of-person Rural Allied Health Workforce
Strategy’ to support the development of a local allied health workforce development
plan.
Recommendation 5:
Recognition:
• The whole-of-person rural retention improvement framework was included and
recommended as an approach to adopt in the rapid review report on strategies
for increasing allied health recruitment and retention in Australia[24] published by
Services for Australian Rural and Remote Allied Health (SARRAH) in July 2019.
Keynote speaker invitations:
• 13th Annual Workforce Planning for Healthcare in Sydney, NSW in November
2019 entitled ‘Results from a two-year trial of a whole-of-person approach to
improve retention of health professionals working in rural public sector health ’.
• Gippsland Allied Health Symposium, in Churchill, Gippsland in June 2020 entitled
‘Importance of engagement of rural communities for attracting and retaining
health professionals in rural Australia’, Federation University, Churchill campus,
June 2020.
Conference plenary sessions invitation:
• North East & Goulburn Valley Allied Health Conference 2019, Beechworth
Victoria in July 2019. Invited to present a 15-minute plenary session entitled
‘Trialling a whole-of-person approach for improving retention of rural-based allied
health professionals’.
Conference presentations:
• NSW Rural Health and Research Congress in Lismore, NSW in October 2019. A
20-minute presentation entitled ‘Trialling a whole-of-person approach for
improving retention of rural-based health professionals’.
Media invitations:
• Interviewed by Jill Rowbotham – Higher Education Writer for The Australian for
an article titled ‘Seeking regional health workers’, published on 24/07/19.
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Recommendation 6:
Invited to lead the Centre for Rural and Remote Mental Health’s response to the National
Rural Health Commissioner’s request for feedback on policy options to improve access,
distribution and quality of rural allied health services, submitted on 7 August 2019.
Conclusion The majority of health professionals live and work in cities, resulting in a global phenomenon
of rural health workforce shortages. Compared to Australians living in urban areas, people
living rurally have reduced access to health services, which negatively affects health-care
equity and health outcomes. A major contributing factor to this inequity and health disparity is
rural health workforce shortages and high turnover. The literature identifies the decision of an
individual to take-up, stay, or leave a rural health position as a complex interaction between
workplace conditions, career building opportunities, and psychosocial and personal factors.
Most of the rural health workforce retention studies undertaken have focused on the influence
of workplace and career building factors, and have, in the main, ignored the psychosocial
determinants. Recently published studies, including my own, have identified the need for a
community engagement approach for successfully attracting, recruiting and retaining a rural
health workforce. For newcomer health workers, social isolation is a major issue and
community engaged solutions are urgently needed, but there are few examples to draw on in
Australia.
My Churchill Fellowship visit to Canada and the interviews I conducted strongly confirmed the
need for a community engaged approach to support the development of effective rural health
workforce strategies. It also highlighted that this is relatively new thinking and there are still few
examples of successful approaches to draw on (the notable exception being the recruiter and
community connector model being used in Marathon, Ontario). However, over the last decade,
rural and remote northern countries have been working in partnership to develop the Recruit &
Retain Framework and this is being used to trial community engaged approaches in the
development of recruitment and retention strategies. My Fellowship provided many
opportunities to build understanding with stakeholders involved in addressing rural health
workforce issues, both in Canada and from other northern countries. It also provided
opportunities to discuss the similar challenges we face in Australia and to promote the whole-
of-person rural retention improvement project and the community engaged approaches being
trialled.
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Internationally, there is an urgent need to strengthen the evidence base on effective
community engaged approaches for recruitment and retention of rural health workforces. I
believe this can be best achieved through greater collaboration among rural and remote
communities in far northern countries and Australia. In Australia, there is need for
strengthened understanding of the importance of community engagement in addressing rural
health workforce issues. Government and rural community support to undertake a longitudinal
trial and evaluation of Marathon’s recruiter and community connector model is critical.
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Appendix A –Canada – Political Map
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Appendix B – Rural Health Workforce Pipeline
Source: Durey et al. (2015)[25]
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