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 ccosgrave@unimelb.edu.au (work) cosgrave.cath@gmail.com (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.

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.

Key Words

Rural & Remote

Social Connection Recruitment &

Retention

Community Engagement

Sense of Belonging

Sense of Place

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 ccosgrave@unimelb.edu.au (work) cosgrave.cath@gmail.com (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.

Figure 1: Conceptual framework of the social determinants of rural health workforce retention. Source: Cosgrave et al. (2019) [12]

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,

~ 3 ~

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

~ 8 ~

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.

~ 10 ~

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.

~ 11 ~

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

~ 12 ~

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

~ 13 ~

• 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

~ 14 ~

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.

~ 15 ~

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.

~ 16 ~

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).

~ 17 ~

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.

~ 18 ~

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

~ 19 ~

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

~ 20 ~

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.

~ 21 ~

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

~ 22 ~

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

~ 24 ~

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.

~ 25 ~

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

~ 26 ~

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.

~ 27 ~

Photo Collage

~ 28 ~

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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

~ 30 ~

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.

~ 32 ~

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:

~ 33 ~

• 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.

~ 34 ~

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).

~ 35 ~

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.

~ 36 ~

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.

~ 37 ~

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.

~ 38 ~

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.

~ 39 ~

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.

~ 40 ~

Appendix A –Canada – Political Map

~ 41 ~

Appendix B – Rural Health Workforce Pipeline

Source: Durey et al. (2015)[25]

~ 42 ~

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